Detection of lung neoplasia by analysis of methylated dna

ABSTRACT

Provided herein is technology for lung neoplasia screening and particularly, but not exclusively, to methods, compositions, and related uses for detecting the presence of lung cancer.

The present application claims priority to U.S. Provisional ApplicationSer. No. 62/332,295, filed May 5, 2016 and U.S. Provisional ApplicationSer. No. 62/462,677, filed Feb. 23, 2017, each of which is incorporatedherein by reference.

FIELD OF THE INVENTION

Provided herein is technology relating to detecting neoplasia andparticularly, but not exclusively, to methods, compositions, and relateduses for detecting neoplasms such as lung cancer.

BACKGROUND OF THE INVENTION

Lung cancer remains the number one cancer killer in the US, andeffective screening approaches are desperately needed. Lung cancer aloneaccounts for 221,000 deaths annually. DNA methylation profiling hasshown unique patterns in DNA promoter regions with cancer and haspotential application for detection of lung malignancies. However,optimally discriminant markers and marker panels are needed.

SUMMARY OF THE INVENTION

Provided herein is a collection of methylated methylation markersassayed on tissue that achieves extremely high discrimination for alltypes of lung cancer while remaining negative in normal lung tissue andbenign nodules. Markers selected from the collection can be used aloneor in a panel, for example, to characterize blood or bodily fluid, withapplications in lung cancer screening and discrimination of malignantfrom benign nodules. In some embodiments, markers from the panel areused to distinguish one form of lung cancer from another, e.g., fordistinguishing the presence of a lung adenocarcinoma or large cellcarcinoma from the presence of a lung small cell carcinoma, or fordetecting mixed pathology carcinomas. Provided herein is technology forscreening markers that provide a high signal-to-noise ratio and a lowbackground level when detected from samples taken from a subject.

Methylation markers and/or panels of markers (e.g., chromosomalregion(s)) having an annotation selected from BARX1, LOC100129726,SPOCK2, TSC22D4, MAX.chr8. 124, RASSF1, ZNF671, ST8SIA1, NKX6_2, FAM59B,DIDO1, MAX_Chr1.110, AGRN, SOBP, MAX_chr10.226, ZMIZ1, MAX_chr8. 145,MAX_chr10.225, PRDM14, ANGPT1, MAX.chr16.50, PTGDR_9, ANKRD13B, DOCK2,MAX_chr19. 163, ZNF132, MAX chr19.372, HOXA9, TRH, SP9, DMRTA2, ARHGEF4,CYP26C1, ZNF781, PTGDR, GRIN2D, MATK, BCAT1, PRKCB_28, ST8SIA_22,FLJ45983, DLX4, SHOX2, EMX1, HOXB2, MAX.chr12.526, BCL2L11, OPLAH,PARP15, KLHDC7B, SLC12A8, BHLHE23, CAPN2, FGF14, FLJ34208, B3GALT6,BIN2_Z, DNMT3A, FERMT3, NFIX, S1PR4, SKI, SUCLG2, TBX15, ZDHHC1, andZNF329 were identified in studies by comparing the methylation state ofmethylation markers from lung cancer samples to the correspondingmarkers in normal (non-cancerous) samples.

As described herein, the technology provides a number of methylationmarkers and subsets thereof (e.g., sets of 2, 3, 4, 5, 6, 7, 8, 9, 10,11, 12 or more markers) with high discrimination for lung cancer and, insome embodiments, with discrimination between lung cancer types.Experiments applied a selection filter to candidate markers to identifymarkers that provide a high signal to noise ratio and a low backgroundlevel to provide high specificity and selectivity for purposes ofcharacterizing biological samples, e.g., for cancer screening ordiagnosis. For example, as described herein below, analysis ofmethylation of combination of 8 markers, SLC12A8, KLHDC7B, PARP15,OPLAH, BCL2L11, MAX.chr12.526, HOXB2, and EMX1, resulted in 98.5%sensitivity (134/136 cancers) for all of the cancer tissues tested, with100% specificity. In another embodiment, a panel of 6 markers (SHOX2,SOBP, ZNF781, CYP26C1, SUCLG2, and SKI) resulted in a sensitivity of92.2% at 93% specificity, and a panel of 4 markers (ZNF781, BARX1, EMX1,and HOXA9) resulted in an overall sensitivity of 96% and specificity of94%.

Accordingly, provided herein is technology related to a method ofprocessing a sample obtained from a subject, the method comprisingassaying a methylation state of one or more marker genes in the sample.In preferred embodiments, the methylation state of the methylationmarker is determined by measuring the amounts of a methylated marker andof a reference marker in the sample, and comparing the amount of themethylated marker to the amount of reference marker in the sample todetermine a methylation state for the methylation marker in the sample.While not limiting the invention to any particular application orapplications, the method finds use, e.g., in characterizing samples froma subject having or suspected of having lung cancer, when themethylation state of the methylation marker is different than amethylation state of that marker assayed in a subject that does not havea neoplasm. In preferred embodiments, the methylation marker comprises achromosomal region having an annotation selected from BARX1,LOC100129726, SPOCK2, TSC22D4, MAX.chr8.124, RASSF1, ZNF671, ST8SIA1,NKX6_2, FAM59B, DIDO1, MAX_Chr1.110, AGRN, SOBP, MAX_chr10.226, ZMIZ1,MAX_chr8.145, MAX_chr10.225, PRDM14, ANGPT1, MAX.chr16.50, PTGDR_9,ANKRD13B, DOCK2, MAX_chr19.163, ZNF132, MAX_chr19.372, HOXA9, TRH, SP9,DMRTA2, ARHGEF4, CYP26C1, ZNF781, PTGDR, GRIN2D, MATK, BCAT1, PRKCB_28,ST8SIA_22, FLJ45983, DLX4, SHOX2, EMX1, HOXB2, MAX.chr12.526, BCL2L11,OPLAH, PARP15, KLHDC7B, SLC12A8, BHLHE23, CAPN2, FGF14, FLJ34208,B3GALT6, BIN2_Z, DNMT3A, FERMT3, NFIX, S1PR4, SKI, SUCLG2, TBX15,ZDHHC1, and ZNF329.

In some embodiments, the technology comprises assaying a plurality ofmarkers, e.g., comprising assaying the methylation states of 2 to 21markers, preferably 2 to 8 markers, preferably 4 to 6 markers. Forexample, in some embodiments, the method comprises analysis of themethylation status of two or more markers selected from SLC12A8,KLHDC7B, PARP15, OPLAH, BCL2L11, MAX.chr12.526, HOXB2, EMX1, CYP26C1,SOBP, SUCLG2, SHOX2, ZDHHC1, NFIX, FLJ45983, HOXA9, B3GALT6, ZNF781,SP9, BARX1, and SKI. In some preferred embodiments, the method comprisesanalysis of the methylation status of a set of markers comprisingSLC12A8, KLHDC7B, PARP15, OPLAH, BCL2L11, MAX.chr12.526, HOXB2, andEMX1. In some embodiments, the method comprises analysis of themethylation status of a set of markers selected from: the groupconsisting of ZNF781, BARX1, and EMX1; the group consisting of SHOX2,SOBP, ZNF781, CYP26C1, SUCLG2, and SKI; the group consisting of SLC12A8,KLHDC7B, PARP15, OPLAH, BCL2L11, MAX.chr12.526, HOXB2, and EMX1; thegroup consisting of SHOX2, SOBP, ZNF781, BTACT, CYP26C1, and DLX4; andthe group consisting of SHOX2, SOBP, ZNF781, CYP26C1, SUCLG2, and SKI.In certain embodiments, the at least one methylation marker comprisesthe group selected from ZNF781, BARX1, and EMX1, and further comprisesSOBP and/or HOXA9.

The technology is not limited in the methylation state assessed. In someembodiments assessing the methylation state of the methylation marker inthe sample comprises determining the methylation state of one base. Insome embodiments, assaying the methylation state of the marker in thesample comprises determining the extent of methylation at a plurality ofbases. Moreover, in some embodiments the methylation state of the markercomprises an increased methylation of the marker relative to a normalmethylation state of the marker. In some embodiments, the methylationstate of the marker comprises a decreased methylation of the markerrelative to a normal methylation state of the marker. In someembodiments the methylation state of the marker comprises a differentpattern of methylation of the marker relative to a normal methylationstate of the marker.

In some embodiments, the technology provides a method of generating arecord reporting a lung neoplasm in a subject, the method comprising thesteps of:

a) assaying a sample from a subject for an amount of at least onemethylated methylation marker gene selected from the group consisting ofBARX1, LOC100129726, SPOCK2, TSC22D4, MAX.chr8.124, RASSFJ, ZNF671,ST8SIA1, NKX6_2, FAM59B, DIDO1, MAX_Chr1.110, AGRN, SOBP, MAX_chr10.226,ZMIZ1, MAX_chr8.145, MAX_chr10.225, PRDM14, ANGPT1, MAX.chr16.50,PTGDR_9, ANKRD13B, DOCK2, MAX_chr19.163, ZNF132, MAX_chr19.372, HOXA9,TRH, SP9, DMRTA2, ARHGEF4, CYP26C1, ZNF781, PTGDR, GRIN2D, MATK, BCAT1,PRKCB_28, ST8SIA_22, FLJ45983, DLX4, SHOX2, EMX1, HOXB2, MAX.chr12.526,BCL2L11, OPLAH, PARP15, KLHDC7B, SLC12A8, BHLHE23, CAPN2, FGF14,FLJ34208, B3GALT6, BIN2_Z, DNMT3A, FERMT3, NFIX, S1PR4, SKI, SUCLG2,TBX15, ZDHHC1, and ZNF329 in a sample obtained from a subject;

b) assaying said sample for an amount of reference marker in saidsample;

c) comparing the amount of said at least one methylated methylationmarker to the amount of reference marker in said sample to determine amethylation state for said at least one methylation marker in saidsample; and d) generating a record reporting the methylation state forsaid at least one marker gene in said sample, wherein the methylationstate of said methylation marker is indicative of the presence orabsence of a lung neoplasm in said subject.

In some embodiments, the sample is assayed for at least two of themarkers, and preferably the at least two methylated marker genes areselected from the group consisting of SLC12A8, KLHDC7B, PARP15, OPLAH,BCL2L11, MAX.chr12.526, HOXB2, EMX1 CYP26C1, SOBP, SUCLG2, SHOX2,ZDHHC1, NFIX, FLJ45983, HOXA9, B3GALT6, ZNF781, SP9, BARX1, and SKI. Incertain preferred embodiments, the method comprises analysis of themethylation status of a set of markers selected from: the groupconsisting of ZNF781, BARX1, and EMX1; the group consisting of SHOX2,SOBP, ZNF781, CYP26C1, SUCLG2, and SKI; the group consisting of SLC12A8,KLHDC7B, PARP15, OPLAH, BCL2L11, MAX.chr12.526, HOXB2, and EMX1; thegroup consisting of SHOX2, SOBP, ZNF781, BTACT, CYP26C1, and DLX4; andthe group consisting of SHOX2, SOBP, ZNF781, CYP26C1, SUCLG2, and SKI.In certain embodiments, the at least one methylation marker comprisesthe group selected from ZNF781, BARX1, and EMX1, and further comprisesSOBP and/or HOXA9. In some embodiments, methylation markers are selectedsuch that the methylation status of said one or more markers isindicative of only one of lung adenocarcinoma, large cell carcinoma,squamous cell carcinoma, or small cell carcinoma. In other embodiments,methylation markers are selected such that the methylation status ofsaid one or more markers is indicative of more than one of lungadenocarcinoma, large cell carcinoma, squamous cell carcinoma, and smallcell carcinoma. In yet other embodiments, methylation markers areselected such that the methylation status of said one or more markers isindicative of any one of or combination of lung adenocarcinoma, largecell carcinoma, squamous cell carcinoma, small cell carcinoma, genericnon-small cell lung cancer, and/or undefined lung carcinoma.

In some embodiments the method used for assaying comprises obtaining asample comprising DNA from a subject, and treating DNA obtained from thesample with a reagent that selectively modifies unmethylated cytosineresidues in the obtained DNA to produce modified residues. In preferredembodiments the reagent comprises a bisulfate reagent.

In some embodiments assaying the methylation state of the methylationmarker in the sample comprises determining the methylation state of onebase, while in other embodiments the assay comprises determining theextent of methylation at a plurality of bases. In some embodiments themethylation state of the marker comprises an increased or decreasedmethylation of the marker relative to a normal methylation state of themarker, e.g., as the marker would appear in a non-cancerous sample,while in some embodiments the methylation state of the marker comprisesa different pattern of methylation of the marker relative to a normalmethylation state of the marker. In preferred embodiments the referencemarker is a methylated reference marker.

The technology is not limited to particular sample types. For example,in some embodiments the sample is a tissue sample, a blood sample, aplasma sample, a serum sample, or a sputum sample. In certain preferredembodiments a tissue sample comprises lung tissue. In certain preferredembodiments, the sample comprises DNA isolated from plasma.

The technology is not limited to any particular method of assaying DNAfrom samples. For example, in some embodiments the assaying comprisesusing polymerase chain reaction, nucleic acid sequencing, massspectrometry, methylation specific nuclease, mass-based separation,and/or target capture. In certain preferred embodiments the assayingcomprises using a flap endonuclease assay. In particularly preferredembodiments the sample DNA and/or reference marker DNA arebisulfite-converted and the assay for determining the methylation levelof the DNA is achieved by a technique comprising the use ofmethylation-specific PCR, quantitative methylation-specific PCR,methylation-sensitive DNA restriction enzyme analysis, quantitativebisulfite pyrosequencing, flap endonuclease assay (e.g., a QUARTS flapendonuclease assay), and/or bisulfite genomic sequencing PCR.

The technology also provides kits. For example, in some embodiments thetechnology provides a kit, comprising a) at least one oligonucleotide,wherein at least a portion of the oligonucleotide specificallyhybridizes to a marker selected from the group consisting of BARX1,LOC100129726, SPOCK2, TSC22D4, MAX.chr8.124, RASSFL ZNF671, ST8SL41,NKX6_2, FAM59B, DIDO1, MAX_Chr1.110, AGRN, SOBP, MAX_chr10.226, ZMIZ1,MAX_chr8.145, MAX_chr10.225, PRDM14, ANGPT1, MAX.chr16.50, PTGDR_9,ANKRD13B, DOCK2, MAX_chr19.163, ZNF132, MAX_chr19.372, HOXA9, TRH, SP9,DMRTA2, ARHGEF4, CYP26C1, ZNF781, PTGDR, GRIN2D, MATK, BCAT1, PRKCB_28,ST8SIA_22, FLJ45983, DLX4, SHOX2, EMX1, HOXB2, MAX.chr12.526, BCL2L11,OPLAH, PARP15, KLHDC7B, SLC12A8, BHLHE23, CAPN2, FGF14, FLJ34208,B3GALT6, BIN2_Z, DNMT3A, FERMT3, NFIX, S1PR4, SKI, SUCLG2, TBX15,ZDHHC1, and ZNF329. In preferred embodiments, the portion of theoligonucleotide that hybridizes to the marker specifically hybridizes tobisulfite-treated DNA comprising the methylation marker. In someembodiments, the kit comprises at least one additional oligonucleotide,wherein at least a portion of the additional oligonucleotidespecifically hybridizes to a reference nucleic acid. In some embodimentsthe kit comprises at least two additional oligonucleotides and, in someembodiments, the kit further comprises a bisulfite reagent.

In certain embodiments at least a portion of the oligonucleotidespecifically hybridizes to a least one the marker selected from thegroup consisting of SLC12A8, KLHDC7B, PARP15, OPLAH, BCL2L11,MAX.chr12.526, HOXB2, EMX1, CYP26C1, SOBP, SUCLG2, SHOX2, ZDHHC1, NFIX,FLJ45983, HOXA9, B3GALT6, ZNF781, SP9, BARX1, and SKI. In preferredembodiments, the kit comprises a set of oligonucleotides, each of whichhybridizes to one marker in a set of markers, the set of markersselected from: the group consisting of ZNF781, BARX1, and EMX1; thegroup consisting of SHOX2, SOBP, ZNF781, CYP26C1, SUCLG2, and SKI thegroup consisting of SLC12A8, KLHDC7B, PARP15, OPLAH, BCL2L11,MAX.chr12.526, HOXB2, and EMX1; the group consisting of SHOX2, SOBP,ZNF781, BTACT, CYP26C1, and DLX4; and the group consisting of SHOX2,SOBP, ZNF781, CYP26C1, SUCLG2, and SKI. In certain embodiments, the setof methylation markers comprises the group selected from ZNF781, BARX1,and EMX1, and further comprises SOBP and/or HOXA9.

In some embodiments, the at least one oligonucleotide in the kit isselected to hybridize to methylation marker(s) that are indicative ofonly one of type of lung carcinoma, e.g., lung adenocarcinoma, largecell carcinoma, squamous cell carcinoma, or small cell carcinoma. Inother embodiments, the at least one oligonucleotide is selected tohybridize to methylation marker(s) that are indicative of more than oneof lung adenocarcinoma, large cell carcinoma, squamous cell carcinoma,and small cell carcinoma. In yet other embodiments, the at least oneoligonucleotide is selected to hybridize to methylation marker(s) thatare indicative of any one of, or any combination of lung adenocarcinoma,large cell carcinoma, squamous cell carcinoma, small cell carcinoma,and/or undefined lung carcinoma.

In preferred embodiments, oligonucleotide(s) provided in the kit areselected from one or more of a capture oligonucleotide, a pair ofnucleic acid primers, a nucleic acid probe, and an invasiveoligonucleotide. In preferred embodiments, oligonucleotide(s)specifically hybridize to bisulfite-treated DNA comprising saidmethylation marker(s).

In some embodiments the kit further comprises a solid support, such amagnetic bead or particle. In preferred embodiments, a solid supportcomprises one or more capture reagents, e.g., oligonucleotidescomplementary said one or more markers genes.

The technology also provides compositions. For example, in someembodiments the technology provides a composition comprising a mixture,e.g., a reaction mixture, that comprises a complex of a target nucleicacid selected from the group consisting of BARX1, LOC100129726, SPOCK2,TSC22D4, MAX.chr8.124, RASSFL ZNF671, ST8SIA1, NKX6_2, FAM59B, DIDO1,MAX_Chr1.110, AGRN, SOBP, MAX_chr10.226, ZMIZ1, MAX_chr8.145,MAX_chr10.225, PRDM14, ANGPT1, MAX.chr16.50, PTGDR_9, ANKRD13B, DOCK2,MAX_chr19.163, ZNF132, MAX chr19.372, HOXA9, TRH, SP9, DMRTA2, ARHGEF4,CYP26C1, ZNF781, PTGDR, GRIN2D, MATK, BCAT1, PRKCB_28, ST8SIA_22,FLJ45983, DLX4, SHOX2, EMX1, HOXB2, MAX.chr12.526, BCL2L11, OPLAH,PARP15, KLHDC7B, SLC12a, BHLHE23, CAPN2, FGF14, FLJ34208, B3GALT6,BIN2_Z, DNMT3A, FERMT3, NFIX, S1PR4, SKI, SUCLG2, TBX15, ZDHHC1, andZNF329 and an oligonucleotide that specifically hybridizes to the targetnucleic acid. In some embodiments, the target nucleic acid isbisulfite-converted target nucleic acid. In preferred embodiments, themixture comprises a complex of a target nucleic acid selected from thegroup consisting of SLC12A8, KLHDC7B, PARP15, OPLAH, BCL2L11,MAX.chr12.526, HOXB2, EMX1, CYP26C1, SOBP, SUCLG2, SHOX2, ZDHHC1, NFIX,FLJ45983, HOXA9, B3GALT6, ZNF781, SP9, BARX1, and SKI, and anoligonucleotide that specifically hybridizes to the target nucleic acid(whether unconverted or bisulfite-converted). Oligonucleotides in themixture include but are not limited to one or more of a captureoligonucleotide, a pair of nucleic acid primers, a hybridization probe,a hydrolysis probe, a flap assay probe, and an invasive oligonucleotide.

In some embodiments, the target nucleic acid in the mixture comprises anucleic acid sequence selected from the group consisting of SEQ ID NOS:1, 6, 11, 16, 21, 28, 33, 38, 43, 48, 53, 58, 63, 68, 73, 78, 86, 91,96, 101, 106, 111, 116, 121, 126, 131, 136, 141, 146, 151, 156, 161,166, 171, 176, 181, 186, 191, 196, 201, 214, 219, 224, 229, 234, 239,247, 252, 257, 262, 267, 272, 277, 282, 287, 292, 298, 303, 308, 313,319, 327, 336, 341, 346, 351, 356, 361, 366, 371, 384, and 403.

In some embodiments, the mixture comprises bisulfate-converted targetnucleic acid that comprises a nucleic acid sequence selected from thegroup consisting of SEQ ID NOS: 2, 7, 12, 17, 22, 29, 34, 39, 44, 49,54, 59, 64, 69, 74, 79, 87, 92, 97, 102, 107, 112, 117, 122, 127, 132,137, 142, 147, 152, 157, 162, 167, 172, 177, 182, 187, 192, 197, 202,210, 215, 220, 225, 230, 235, 240, 248, 253, 258, 263, 268, 273, 278,283, 288, 293, 299, 304, 309, 314, 320, 328, 337, 342, 347, 352, 357,362, 367, 372, 385, and 404.

In some embodiments, an oligonucleotide in said mixture comprises areporter molecule, and in preferred embodiments, the reporter moleculecomprises a fluorophore. In some embodiments the oligonucleotidecomprises a flap sequence. In some embodiments the mixture furthercomprises one or more of a FRET cassette; a FEN-1 endonuclease and/or athermostable DNA polymerase, preferably a bacterial DNA polymerase.

DEFINITIONS

To facilitate an understanding of the present technology, a number ofterms and phrases are defined below. Additional definitions are setforth throughout the detailed description.

Throughout the specification and claims, the following terms take themeanings explicitly associated herein, unless the context clearlydictates otherwise. The phrase “in one embodiment” as used herein doesnot necessarily refer to the same embodiment, though it may.Furthermore, the phrase “in another embodiment” as used herein does notnecessarily refer to a different embodiment, although it may. Thus, asdescribed below, various embodiments of the invention may be readilycombined, without departing from the scope or spirit of the invention.

In addition, as used herein, the term “or” is an inclusive “or” operatorand is equivalent to the term “and/or” unless the context clearlydictates otherwise. The term “based on” is not exclusive and allows forbeing based on additional factors not described, unless the contextclearly dictates otherwise. In addition, throughout the specification,the meaning of “a”, “an”, and “the” include plural references. Themeaning of “in” includes “in” and “on.”

The transitional phrase “consisting essentially of” as used in claims inthe present application limits the scope of a claim to the specifiedmaterials or steps “and those that do not materially affect the basicand novel characteristic(s)” of the claimed invention, as discussed inIn re Herz, 537 E2d 549, 551-52, 190 USPQ 461, 463 (CCPR 1976). Forexample, a composition “consisting essentially of” recited elements maycontain an unrecited contaminant at a level such that, though present,the contaminant does not alter the function of the recited compositionas compared to a pure composition, i.e., a composition “consisting of”the recited components.

As used herein, “methylation” refers to cytosine methylation atpositions C5 or N4 of cytosine, the N6 position of adenine, or othertypes of nucleic acid methylation. In vitro amplified DNA is usuallyunmethylated because typical in vitro DNA amplification methods do notretain the methylation pattern of the amplification template. However,“unmethylated DNA” or “methylated DNA” can also refer to amplified DNAwhose original template was unmethylated or methylated, respectively.

Accordingly, as used herein a “methylated nucleotide” or a “methylatednucleotide base” refers to the presence of a methyl moiety on anucleotide base, where the methyl moiety is not present in a recognizedtypical nucleotide base. For example, cytosine does not contain a methylmoiety on its pyrimidine ring, but 5-methylcytosine contains a methylmoiety at position 5 of its pyrimidine ring. Therefore, cytosine is nota methylated nucleotide and 5-methylcytosine is a methylated nucleotide.In another example, thymine contains a methyl moiety at position 5 ofits pyrimidine ring; however, for purposes herein, thymine is notconsidered a methylated nucleotide when present in DNA since thymine isa typical nucleotide base of DNA.

As used herein, a “methylated nucleic acid molecule” refers to a nucleicacid molecule that contains one or more methylated nucleotides.

As used herein, a “methylation state”, “methylation profile”, and“methylation status” of a nucleic acid molecule refers to the presenceof absence of one or more methylated nucleotide bases in the nucleicacid molecule. For example, a nucleic acid molecule containing amethylated cytosine is considered methylated (e.g., the methylationstate of the nucleic acid molecule is methylated). A nucleic acidmolecule that does not contain any methylated nucleotides is consideredunmethylated. In some embodiments, a nucleic acid may be characterizedas “unmethylated” if it is not methylated at a specific locus (e.g., thelocus of a specific single CpG dinucleotide) or specific combination ofloci, even if it is methylated at other loci in the same gene ormolecule.

The methylation state of a particular nucleic acid sequence (e.g., agene marker or DNA region as described herein) can indicate themethylation state of every base in the sequence or can indicate themethylation state of a subset of the bases (e.g., of one or morecytosines) within the sequence, or can indicate information regardingregional methylation density within the sequence with or withoutproviding precise information of the locations within the sequence themethylation occurs. As used herein, the terms “marker gene” and “marker”are used interchangeably to refer to DNA that is associated with acondition, e.g., cancer, regardless of whether the marker region is in acoding region of DNA. Markers may include, e.g., regulatory regions,flanking regions, intergenic regions, etc.

The methylation state of a nucleotide locus in a nucleic acid moleculerefers to the presence or absence of a methylated nucleotide at aparticular locus in the nucleic acid molecule. For example, themethylation state of a cytosine at the 7th nucleotide in a nucleic acidmolecule is methylated when the nucleotide present at the 7th nucleotidein the nucleic acid molecule is 5-methylcytosine. Similarly, themethylation state of a cytosine at the 7th nucleotide in a nucleic acidmolecule is unmethylated when the nucleotide present at the 7thnucleotide in the nucleic acid molecule is cytosine (and not5-methylcytosine).

The methylation status can optionally be represented or indicated by a“methylation value” (e.g., representing a methylation frequency,fraction, ratio, percent, etc.) A methylation value can be generated,for example, by quantifying the amount of intact nucleic acid presentfollowing restriction digestion with a methylation dependent restrictionenzyme or by comparing amplification profiles after bisulfite reactionor by comparing sequences of bisulfite-treated and untreated nucleicacids. Accordingly, a value, e.g., a methylation value, represents themethylation status and can thus be used as a quantitative indicator ofmethylation status across multiple copies of a locus. This is ofparticular use when it is desirable to compare the methylation status ofa sequence in a sample to a threshold or reference value.

As used herein, “methylation frequency” or “methylation percent (%)”refer to the number of instances in which a molecule or locus ismethylated relative to the number of instances the molecule or locus isunmethylated.

As such, the methylation state describes the state of methylation of anucleic acid (e.g., a genomic sequence). In addition, the methylationstate refers to the characteristics of a nucleic acid segment at aparticular genomic locus relevant to methylation. Such characteristicsinclude, but are not limited to, whether any of the cytosine (C)residues within this DNA sequence are methylated, the location ofmethylated C residue(s), the frequency or percentage of methylated Cthroughout any particular region of a nucleic acid, and allelicdifferences in methylation due to, e.g., difference in the origin of thealleles. The terms “methylation state”, “methylation profile”, and“methylation status” also refer to the relative concentration, absoluteconcentration, or pattern of methylated C or unmethylated C throughoutany particular region of a nucleic acid in a biological sample. Forexample, if the cytosine (C) residue(s) within a nucleic acid sequenceare methylated it may be referred to as “hypermethylated” or having“increased methylation”, whereas if the cytosine (C) residue(s) within aDNA sequence are not methylated it may be referred to as“hypomethylated” or having “decreased methylation”. Likewise, if thecytosine (C) residue(s) within a nucleic acid sequence are methylated ascompared to another nucleic acid sequence (e.g., from a different regionor from a different individual, etc.) that sequence is consideredhypermethylated or having increased methylation compared to the othernucleic acid sequence. Alternatively, if the cytosine (C) residue(s)within a DNA sequence are not methylated as compared to another nucleicacid sequence (e.g., from a different region or from a differentindividual, etc.) that sequence is considered hypomethylated or havingdecreased methylation compared to the other nucleic acid sequence.Additionally, the term “methylation pattern” as used herein refers tothe collective sites of methylated and unmethylated nucleotides over aregion of a nucleic acid. Two nucleic acids may have the same or similarmethylation frequency or methylation percent but have differentmethylation patterns when the number of methylated and unmethylatednucleotides is the same or similar throughout the region but thelocations of methylated and unmethylated nucleotides are different.Sequences are said to be “differentially methylated” or as having a“difference in methylation” or having a “different methylation state”when they differ in the extent (e.g., one has increased or decreasedmethylation relative to the other), frequency, or pattern ofmethylation. The term “differential methylation” refers to a differencein the level or pattern of nucleic acid methylation in a cancer positivesample as compared with the level or pattern of nucleic acid methylationin a cancer negative sample. It may also refer to the difference inlevels or patterns between patients that have recurrence of cancer aftersurgery versus patients who not have recurrence. Differentialmethylation and specific levels or patterns of DNA methylation areprognostic and predictive biomarkers, e.g., once the correct cut-off orpredictive characteristics have been defined.

Methylation state frequency can be used to describe a population ofindividuals or a sample from a single individual. For example, anucleotide locus having a methylation state frequency of 50% ismethylated in 50% of instances and unmethylated in 50% of instances.Such a frequency can be used, for example, to describe the degree towhich a nucleotide locus or nucleic acid region is methylated in apopulation of individuals or a collection of nucleic acids. Thus, whenmethylation in a first population or pool of nucleic acid molecules isdifferent from methylation in a second population or pool of nucleicacid molecules, the methylation state frequency of the first populationor pool will be different from the methylation state frequency of thesecond population or pool. Such a frequency also can be used, forexample, to describe the degree to which a nucleotide locus or nucleicacid region is methylated in a single individual. For example, such afrequency can be used to describe the degree to which a group of cellsfrom a tissue sample are methylated or unmethylated at a nucleotidelocus or nucleic acid region.

As used herein a “nucleotide locus” refers to the location of anucleotide in a nucleic acid molecule. A nucleotide locus of amethylated nucleotide refers to the location of a methylated nucleotidein a nucleic acid molecule.

Typically, methylation of human DNA occurs on a dinucleotide sequenceincluding an adjacent guanine and cytosine where the cytosine is located5′ of the guanine (also termed CpG dinucleotide sequences). Mostcytosines within the CpG dinucleotides are methylated in the humangenome, however some remain unmethylated in specific CpG dinucleotiderich genomic regions, known as CpG islands (see, e.g., Antequera, et al.(1990) Cell 62: 503-514).

As used herein, a “CpG island” refers to a G:C-rich region of genomicDNA containing an increased number of CpG dinucleotides relative tototal genomic DNA. A CpG island can be at least 100, 200, or more basepairs in length, where the G:C content of the region is at least 50% andthe ratio of observed CpG frequency over expected frequency is 0.6; insome instances, a CpG island can be at least 500 base pairs in length,where the G:C content of the region is at least 55%) and the ratio ofobserved CpG frequency over expected frequency is 0.65. The observed CpGfrequency over expected frequency can be calculated according to themethod provided in Gardiner-Garden et al (1987)1 Mol. Biol. 196:261-281. For example, the observed CpG frequency over expected frequencycan be calculated according to the formula R=(A×B)/(C×D), where R is theratio of observed CpG frequency over expected frequency, A is the numberof CpG dinucleotides in an analyzed sequence, B is the total number ofnucleotides in the analyzed sequence, C is the total number of Cnucleotides in the analyzed sequence, and D is the total number of Gnucleotides in the analyzed sequence. Methylation state is typicallydetermined in CpG islands, e.g., at promoter regions. It will beappreciated though that other sequences in the human genome are prone toDNA methylation such as CpA and CpT (see Ramsahoye (2000) Proc. Natl.Acad. Sci. USA 97: 5237-5242; Salmon and Kaye (1970) Biochim. Biophys.Acta. 204: 340-351; Grafstrom (1985) Nucleic Acids Res. 13: 2827-2842;Nyce (1986) Nucleic Acids Res. 14: 4353-4367; Woodcock (1987) Biochem.Biophys. Res. Commun. 145: 888-894).

As used herein, a “methylation-specific reagent” refers to a reagentthat modifies a nucleotide of the nucleic acid molecule as a function ofthe methylation state of the nucleic acid molecule, or amethylation-specific reagent, refers to a compound or composition orother agent that can change the nucleotide sequence of a nucleic acidmolecule in a manner that reflects the methylation state of the nucleicacid molecule. Methods of treating a nucleic acid molecule with such areagent can include contacting the nucleic acid molecule with thereagent, coupled with additional steps, if desired, to accomplish thedesired change of nucleotide sequence. Such methods can be applied in amanner in which unmethylated nucleotides (e.g., each unmethylatedcytosine) is modified to a different nucleotide. For example, in someembodiments, such a reagent can deaminate unmethylated cytosinenucleotides to produce deoxy uracil residues. An exemplary reagent is abisulfite reagent.

The term “bisulfite reagent” refers to a reagent comprising bisulfite,disulfite, hydrogen sulfite, or combinations thereof, useful asdisclosed herein to distinguish between methylated and unmethylated CpGdinucleotide sequences. Methods of said treatment are known in the art(e.g., PCT/EP2004/011715 and WO 2013/116375, each of which isincorporated by reference in its entirety). In some embodiments,bisulfite treatment is conducted in the presence of denaturing solventssuch as but not limited to n-alkyleneglycol or diethylene glycoldimethyl ether (DME), or in the presence of dioxane or dioxanederivatives. In some embodiments the denaturing solvents are used inconcentrations between 1% and 35% (v/v). In some embodiments, thebisulfite reaction is carried out in the presence of scavengers such asbut not limited to chromane derivatives, e.g.,6-hydroxy-2,5,7,8,-tetramethylchromane 2-carboxylic acid ortrihydroxybenzone acid and derivates thereof, e.g., Gallic acid (see:PCT/EP2004/011715, which is incorporated by reference in its entirety).In certain preferred embodiments, the bisulfite reaction comprisestreatment with ammonium hydrogen sulfite, e.g., as described in WO2013/116375.

A change in the nucleic acid nucleotide sequence by amethylation—specific reagent can also result in a nucleic acid moleculein which each methylated nucleotide is modified to a differentnucleotide.

The term “methylation assay” refers to any assay for determining themethylation state of one or more CpG dinucleotide sequences within asequence of a nucleic acid.

As used herein, the “sensitivity” of a given marker (or set of markersused together) refers to the percentage of samples that report a DNAmethylation value above a threshold value that distinguishes betweenneoplastic and non-neoplastic samples. In some embodiments, a positiveis defined as a histology-confirmed neoplasia that reports a DNAmethylation value above a threshold value (e.g., the range associatedwith disease), and a false negative is defined as a histology-confirmedneoplasia that reports a DNA methylation value below the threshold value(e.g., the range associated with no disease). The value of sensitivity,therefore, reflects the probability that a DNA methylation measurementfor a given marker obtained from a known diseased sample will be in therange of disease-associated measurements. As defined here, the clinicalrelevance of the calculated sensitivity value represents an estimationof the probability that a given marker would detect the presence of aclinical condition when applied to a subject with that condition.

As used herein, the “specificity” of a given marker (or set of markersused together) refers to the percentage of non-neoplastic samples thatreport a DNA methylation value below a threshold value thatdistinguishes between neoplastic and non-neoplastic samples. In someembodiments, a negative is defined as a histology-confirmednon-neoplastic sample that reports a DNA methylation value below thethreshold value (e.g., the range associated with no disease) and a falsepositive is defined as a histology-confirmed non-neoplastic sample thatreports a DNA methylation value above the threshold value (e.g., therange associated with disease). The value of specificity, therefore,reflects the probability that a DNA methylation measurement for a givenmarker obtained from a known non-neoplastic sample will be in the rangeof non-disease associated measurements. As defined here, the clinicalrelevance of the calculated specificity value represents an estimationof the probability that a given marker would detect the absence of aclinical condition when applied to a patient without that condition.

As used herein, a “selected nucleotide” refers to one nucleotide of thefour typically occurring nucleotides in a nucleic acid molecule (C, G,T, and A for DNA and C, G, U, and A for RNA), and can include methylatedderivatives of the typically occurring nucleotides (e.g., when C is theselected nucleotide, both methylated and unmethylated C are includedwithin the meaning of a selected nucleotide), whereas a methylatedselected nucleotide refers specifically to a nucleotide that istypically methylated and an unmethylated selected nucleotides refersspecifically to a nucleotide that typically occurs in unmethylated form.

The terms “methylation-specific restriction enzyme” or“methylation-sensitive restriction enzyme” refers to an enzyme thatselectively digests a nucleic acid dependent on the methylation state ofits recognition site. In the case of a restriction enzyme thatspecifically cuts if the recognition site is not methylated or ishemi-methylated, the cut will not take place or will take place with asignificantly reduced efficiency if the recognition site is methylated.In the case of a restriction enzyme that specifically cuts if therecognition site is methylated, the cut will not take place or will takeplace with a significantly reduced efficiency if the recognition site isnot methylated. Preferred are methylation-specific restriction enzymes,the recognition sequence of which contains a CG dinucleotide (forinstance a recognition sequence such as CGCG or CCCGGG). Furtherpreferred for some embodiments are restriction enzymes that do not cutif the cytosine in this dinucleotide is methylated at the carbon atomC5.

The term “primer” refers to an oligonucleotide, whether occurringnaturally as, e.g., a nucleic acid fragment from a restriction digest,or produced synthetically, that is capable of acting as a point ofinitiation of synthesis when placed under conditions in which synthesisof a primer extension product that is complementary to a nucleic acidtemplate strand is induced, (e.g., in the presence of nucleotides and aninducing agent such as a DNA polymerase, and at a suitable temperatureand pH). The primer is preferably single stranded for maximum efficiencyin amplification, but may alternatively be double stranded. If doublestranded, the primer is first treated to separate its strands beforebeing used to prepare extension products. Preferably, the primer is anoligodeoxyribonucleotide. The primer must be sufficiently long to primethe synthesis of extension products in the presence of the inducingagent. The exact lengths of the primers will depend on many factors,including temperature, source of primer, and the use of the method.

The term “probe” refers to an oligonucleotide (e.g., a sequence ofnucleotides), whether occurring naturally as in a purified restrictiondigest or produced synthetically, recombinantly, or by PCRamplification, that is capable of hybridizing to another oligonucleotideof interest. A probe may be single-stranded or double-stranded. Probesare useful in the detection, identification, and isolation of particulargene sequences (e.g., a “capture probe”). It is contemplated that anyprobe used in the present invention may, in some embodiments, be labeledwith any “reporter molecule,” so that is detectable in any detectionsystem, including, but not limited to enzyme (e.g., ELISA, as well asenzyme-based histochemical assays), fluorescent, radioactive, andluminescent systems. It is not intended that the present invention belimited to any particular detection system or label.

The term “target,” as used herein refers to a nucleic acid sought to besorted out from other nucleic acids, e.g., by probe binding,amplification, isolation, capture, etc. For example, when used inreference to the polymerase chain reaction, “target” refers to theregion of nucleic acid bounded by the primers used for polymerase chainreaction, while when used in an assay in which target DNA is notamplified, e.g., in some embodiments of an invasive cleavage assay, atarget comprises the site at which a probe and invasive oligonucleotides(e.g., INVADER oligonucleotide) bind to form an invasive cleavagestructure, such that the presence of the target nucleic acid can bedetected. A “segment” is defined as a region of nucleic acid within thetarget sequence.

The term “marker”, as used herein, refers to a substance (e.g., anucleic acid, or a region of a nucleic acid, or a protein) that may beused to distinguish non-normal cells (e.g., cancer cells) from normalcells (non-cancerous cells), e.g., based on presence, absence, or status(e.g., methylation state) of the marker substance. As used herein“normal” methylation of a marker refers to a degree of methylationtypically found in normal cells, e.g., in non-cancerous cells.

The term “neoplasm” as used herein refers to any new and abnormal growthof tissue. Thus, a neoplasm can be a premalignant neoplasm or amalignant neoplasm.

The term “neoplasm-specific marker,” as used herein, refers to anybiological material or element that can be used to indicate the presenceof a neoplasm. Examples of biological materials include, withoutlimitation, nucleic acids, polypeptides, carbohydrates, fatty acids,cellular components (e.g., cell membranes and mitochondria), and wholecells. In some instances, markers are particular nucleic acid regions(e.g., genes, intragenic regions, specific loci, etc.). Regions ofnucleic acid that are markers may be referred to, e.g., as “markergenes,” “marker regions,” “marker sequences,” “marker loci,” etc.

The term “sample” is used in its broadest sense. In one sense it canrefer to an animal cell or tissue. In another sense, it refers to aspecimen or culture obtained from any source, as well as biological andenvironmental samples. Biological samples may be obtained from plants oranimals (including humans) and encompass fluids, solids, tissues, andgases. Environmental samples include environmental material such assurface matter, soil, water, and industrial samples. These examples arenot to be construed as limiting the sample types applicable to thepresent invention.

As used herein, the terms “patient” or “subject” refer to organisms tobe subject to various tests provided by the technology. The term“subject” includes animals, preferably mammals, including humans. In apreferred embodiment, the subject is a primate. In an even morepreferred embodiment, the subject is a human. Further with respect todiagnostic methods, a preferred subject is a vertebrate subject. Apreferred vertebrate is warm-blooded; a preferred warm-bloodedvertebrate is a mammal. A preferred mammal is most preferably a human.As used herein, the term “subject' includes both human and animalsubjects. Thus, veterinary therapeutic uses are provided herein. Assuch, the present technology provides for the diagnosis of mammals suchas humans, as well as those mammals of importance due to beingendangered, such as Siberian tigers; of economic importance, such asanimals raised on farms for consumption by humans; and/or animals ofsocial importance to humans, such as animals kept as pets or in zoos.Examples of such animals include but are not limited to: carnivores suchas cats and dogs; swine, including pigs, hogs, and wild boars; ruminantsand/or ungulates such as cattle, oxen, sheep, giraffes, deer, goats,bison, and camels; pinnipeds; and horses. Thus, also provided is thediagnosis and treatment of livestock, including, but not limited to,domesticated swine, ruminants, ungulates, horses (including racehorses), and the like. The presently-disclosed subject matter furtherincludes a system for diagnosing a lung cancer in a subject. The systemcan be provided, for example, as a commercial kit that can be used toscreen for a risk of lung cancer or diagnose a lung cancer in a subjectfrom whom a biological sample has been collected. An exemplary systemprovided in accordance with the present technology includes assessingthe methylation state of a marker described herein.

The term “amplifying” or “amplification” in the context of nucleic acidsrefers to the production of multiple copies of a polynucleotide, or aportion of the polynucleotide, typically starting from a small amount ofthe polynucleotide (e.g., a single polynucleotide molecule), where theamplification products or amplicons are generally detectable.Amplification of polynucleotides encompasses a variety of chemical andenzymatic processes. The generation of multiple DNA copies from one or afew copies of a target or template DNA molecule during a polymerasechain reaction (PCR) or a ligase chain reaction (LCR; see, e.g., U.S.Pat. No. 5,494,810; herein incorporated by reference in its entirety)are forms of amplification. Additional types of amplification include,but are not limited to, allele-specific PCR (see, e.g., U.S. Pat. No.5,639,611; herein incorporated by reference in its entirety), assemblyPCR (see, e.g., U.S. Pat. No. 5,965,408; herein incorporated byreference in its entirety), helicase-dependent amplification (see, e.g.,U.S. Pat. No. 7,662,594; herein incorporated by reference in itsentirety), hot-start PCR (see, e.g., U.S. Pat. Nos. 5,773,258 and5,338,671; each herein incorporated by reference in their entireties),intersequence-specific PCR, inverse PCR (see, e.g., Triglia, et al.(1988) Nucleic Acids Res., 16:8186; herein incorporated by reference inits entirety), ligation-mediated PCR (see, e.g., Guilfoyle, R. et al.,Nucleic Acids Research, 25:1854-1858 (1997); U.S. Pat. No. 5,508,169;each of which are herein incorporated by reference in their entireties),methylation-specific PCR (see, e.g., Herman, et al., (1996) PNAS 93(13)9821-9826; herein incorporated by reference in its entirety), miniprimerPCR, multiplex ligation-dependent probe amplification (see, e.g.,Schouten, et al., (2002) Nucleic Acids Research 30(12): e57; hereinincorporated by reference in its entirety), multiplex PCR (see, e.g.,Chamberlain, et al., (1988) Nucleic Acids Research 16(23) 11141-11156;Ballabio, et al., (1990) Human Genetics 84(6) 571-573; Hayden, et al.,(2008) BMC Genetics 9:80; each of which are herein incorporated byreference in their entireties), nested PCR, overlap-extension PCR (see,e.g., Higuchi, et al., (1988) Nucleic Acids Research 16(15) 7351-7367;herein incorporated by reference in its entirety), real time PCR (see,e.g., Higuchi, et al., (1992) Biotechnology 10:413-417; Higuchi, et al.,(1993) Biotechnology 11:1026-1030; each of which are herein incorporatedby reference in their entireties), reverse transcription PCR (see, e.g.,Bustin, S. A. (2000) J. Molecular Endocrinology 25:169-193; hereinincorporated by reference in its entirety), solid phase PCR, thermalasymmetric interlaced PCR, and Touchdown PCR (see, e.g., Don, et al.,Nucleic Acids Research (1991) 19(14) 4008; Roux, K. (1994) Biotechniques16(5) 812-814; Hecker, et al., (1996) Biotechniques 20(3) 478-485; eachof which are herein incorporated by reference in their entireties).Polynucleotide amplification also can be accomplished using digital PCR(see, e.g., Kalinina, et al., Nucleic Acids Research. 25; 1999-2004,(1997); Vogelstein and Kinzler, Proc Natl Acad Sci USA. 96; 9236-41,(1999); International Patent Publication No. WO05023091A2; US PatentApplication Publication No. 20070202525; each of which are incorporatedherein by reference in their entireties).

The term “polymerase chain reaction” (“PCR”) refers to the method of K.B. Mullis U.S. Pat. Nos. 4,683,195, 4,683,202, and 4,965,188, thatdescribe a method for increasing the concentration of a segment of atarget sequence in a mixture of genomic or other DNA or RNA, withoutcloning or purification. This process for amplifying the target sequenceconsists of introducing a large excess of two oligonucleotide primers tothe DNA mixture containing the desired target sequence, followed by aprecise sequence of thermal cycling in the presence of a DNA polymerase.The two primers are complementary to their respective strands of thedouble stranded target sequence. To effect amplification, the mixture isdenatured and the primers then annealed to their complementary sequenceswithin the target molecule. Following annealing, the primers areextended with a polymerase so as to form a new pair of complementarystrands. The steps of denaturation, primer annealing, and polymeraseextension can be repeated many times (i.e., denaturation, annealing andextension constitute one “cycle”; there can be numerous “cycles”) toobtain a high concentration of an amplified segment of the desiredtarget sequence. The length of the amplified segment of the desiredtarget sequence is determined by the relative positions of the primerswith respect to each other, and therefore, this length is a controllableparameter. By virtue of the repeating aspect of the process, the methodis referred to as the “polymerase chain reaction” (“PCR”). Because thedesired amplified segments of the target sequence become the predominantsequences (in terms of concentration) in the mixture, they are said tobe “PCR amplified” and are “PCR products” or “amplicons.” Those of skillin the art will understand the term “PCR” encompasses many variants ofthe originally described method using, e.g., real time PCR, nested PCR,reverse transcription PCR (RT-PCR), single primer and arbitrarily primedPCR, etc.

As used herein, the term “nucleic acid detection assay” refers to anymethod of determining the nucleotide composition of a nucleic acid ofinterest. Nucleic acid detection assay include but are not limited to,DNA sequencing methods, probe hybridization methods, structure specificcleavage assays (e.g., the INVADER assay, (Hologic, Inc.) and aredescribed, e.g., in U.S. Pat. Nos. 5,846,717, 5,985,557, 5,994,069,6,001,567, 6,090,543, and 6,872,816; Lyamichev et al., Nat. Biotech.,17:292 (1999), Hall et al., PNAS, USA, 97:8272 (2000), and US Pat. No.9,096,893, each of which is herein incorporated by reference in itsentirety for all purposes); enzyme mismatch cleavage methods (e.g.,Variagenics, U.S. Pat. Nos. 6,110,684, 5,958,692, 5,851,770, hereinincorporated by reference in their entireties); polymerase chainreaction (PCR), described above; branched hybridization methods (e.g.,Chiron, U.S. Pat. Nos. 5,849,481, 5,710,264, 5,124,246, and 5,624,802,herein incorporated by reference in their entireties); rolling circlereplication (e.g., U.S. Pat. Nos. 6,210,884, 6,183,960 and 6,235,502,herein incorporated by reference in their entireties); NASBA (e.g., U.S.Pat. No. 5,409,818, herein incorporated by reference in its entirety);molecular beacon technology (e.g., U.S. Pat. No. 6,150,097, hereinincorporated by reference in its entirety); E-sensor technology(Motorola, U.S. Pat. Nos. 6,248,229, 6,221,583, 6,013,170, and6,063,573, herein incorporated by reference in their entireties);cycling probe technology (e.g., U.S. Pat. Nos. 5,403,711, 5,011,769, and5,660,988, herein incorporated by reference in their entireties); DadeBehring signal amplification methods (e.g., U.S. Pat. Nos. 6,121,001,6,110,677, 5,914,230, 5,882,867, and 5,792,614, herein incorporated byreference in their entireties); ligase chain reaction (e.g., BaranayProc. Natl. Acad. Sci USA 88, 189-93 (1991)); and sandwich hybridizationmethods (e.g., U.S. Pat. No. 5,288,609, herein incorporated by referencein its entirety).

In some embodiments, target nucleic acid is amplified (e.g., by PCR) andamplified nucleic acid is detected simultaneously using an invasivecleavage assay. Assays configured for performing a detection assay(e.g., invasive cleavage assay) in combination with an amplificationassay are described in U.S. Pat. No. 9,096,893, incorporated herein byreference in its entirety for all purposes. Additional amplificationplus invasive cleavage detection configurations, termed the QUARTSmethod, are described in, e.g., in U.S. Pat. Nos. 8,361,720; 8,715,937;8,916,344; and 9,212,392, each of which is incorporated herein byreference for all purposes. The term “invasive cleavage structure” asused herein refers to a cleavage structure comprising i) a targetnucleic acid, ii) an upstream nucleic acid (e.g., an invasive or“INVADER” oligonucleotide), and iii) a downstream nucleic acid (e.g., aprobe), where the upstream and downstream nucleic acids anneal tocontiguous regions of the target nucleic acid, and where an overlapforms between the a 3′ portion of the upstream nucleic acid and duplexformed between the downstream nucleic acid and the target nucleic acid.An overlap occurs where one or more bases from the upstream anddownstream nucleic acids occupy the same position with respect to atarget nucleic acid base, whether or not the overlapping base(s) of theupstream nucleic acid are complementary with the target nucleic acid,and whether or not those bases are natural bases or non-natural bases.In some embodiments, the 3′ portion of the upstream nucleic acid thatoverlaps with the downstream duplex is a non-base chemical moiety suchas an aromatic ring structure, e.g., as disclosed, for example, in U.S.Pat. No. 6,090,543, incorporated herein by reference in its entirety. Insome embodiments, one or more of the nucleic acids may be attached toeach other, e.g., through a covalent linkage such as nucleic acidstem-loop, or through a non-nucleic acid chemical linkage (e.g., amulti-carbon chain). As used herein, the term “flap endonuclease assay”includes “INVADER” invasive cleavage assays and QuARTS assays, asdescribed above.

The term “probe oligonucleotide” or “flap oligonucleotide” when used inreference to flap assay, refers to an oligonucleotide that interactswith a target nucleic acid to form a cleavage structure in the presenceof an invasive oligonucleotide.

The term “invasive oligonucleotide” refers to an oligonucleotide thathybridizes to a target nucleic acid at a location adjacent to the regionof hybridization between a probe and the target nucleic acid, whereinthe 3′ end of the invasive oligonucleotide comprises a portion (e.g., achemical moiety, or one or more nucleotides) that overlaps with theregion of hybridization between the probe and target. The 3′ terminalnucleotide of the invasive oligonucleotide may or may not base pair anucleotide in the target. In some embodiments, the invasiveoligonucleotide contains sequences at its 3′ end that are substantiallythe same as sequences located at the 5′ end of a portion of the probeoligonucleotide that anneals to the target strand.

The term “flap endonuclease” or “FEN,” as used herein, refers to a classof nucleolytic enzymes, typically 5′ nucleases, that act asstructure-specific endonucleases on DNA structures with a duplexcontaining a single stranded 5′ overhang, or flap, on one of the strandsthat is displaced by another strand of nucleic acid (e.g., such thatthere are overlapping nucleotides at the junction between the single anddouble-stranded DNA). FENs catalyze hydrolytic cleavage of thephosphodiester bond at the junction of single and double stranded DNA,releasing the overhang, or the flap. Flap endonucleases are reviewed byCeska and Savers (Trends Biochem. Sci. 1998 23:331-336) and Liu et al(Annu. Rev. Biochem. 2004 73: 589-615; herein incorporated by referencein its entirety). FENs may be individual enzymes, multi-subunit enzymes,or may exist as an activity of another enzyme or protein complex (e.g.,a DNA polymerase).

A flap endonuclease may be thermostable. For example, FEN-1 flapendonuclease from archival thermophiles organisms are typicalthermostable. As used herein, the term “FEN-1” refers to anon-polymerase flap endonuclease from a eukaryote or archaeal organism.See, e.g., WO 02/070755, and Kaiser M.W., et al. (1999) J. Biol. Chem.,274:21387, which are incorporated by reference herein in theirentireties for all purposes.

As used herein, the term “cleaved flap” refers to a single-strandedoligonucleotide that is a cleavage product of a flap assay.

The term “cassette,” when used in reference to a flap cleavage reaction,refers to an oligonucleotide or combination of oligonucleotidesconfigured to generate a detectable signal in response to cleavage of aflap or probe oligonucleotide, e.g., in a primary or first cleavagestructure formed in a flap cleavage assay. In preferred embodiments, thecassette hybridizes to a non-target cleavage product produced bycleavage of a flap oligonucleotide to form a second overlapping cleavagestructure, such that the cassette can then be cleaved by the sameenzyme, e.g., a FEN-1 endonuclease.

In some embodiments, the cassette is a single oligonucleotide comprisinga hairpin portion (i.e., a region wherein one portion of the cassetteoligonucleotide hybridizes to a second portion of the sameoligonucleotide under reaction conditions, to form a duplex). In otherembodiments, a cassette comprises at least two oligonucleotidescomprising complementary portions that can form a duplex under reactionconditions. In preferred embodiments, the cassette comprises a label,e.g., a fluorophore. In particularly preferred embodiments, a cassettecomprises labeled moieties that produce a FRET effect.

As used herein, the term “FRET” refers to fluorescence resonance energytransfer, a process in which moieties (e.g., fluorophores) transferenergy e.g., among themselves, or, from a fluorophore to anon-fluorophore (e.g., a quencher molecule). In some circumstances, FRETinvolves an excited donor fluorophore transferring energy to alower-energy acceptor fluorophore via a short-range (e.g., about 10 nmor less) dipole-dipole interaction. In other circumstances, FRETinvolves a loss of fluorescence energy from a donor and an increase influorescence in an acceptor fluorophore. In still other forms of FRET,energy can be exchanged from an excited donor fluorophore to anon-fluorescing molecule (e.g., a “dark” quenching molecule). FRET isknown to those of skill in the art and has been described (See, e.g.,Stryer et al., 1978, Ann. Rev. Biochem., 47:819; Selvin, 1995, MethodsEnzymol., 246:300; Orpana, 2004 Biomol Eng 21, 45-50; Olivier, 2005Mutant Res 573, 103-110, each of which is incorporated herein byreference in its entirety).

In an exemplary flap detection assay, an invasive oligonucleotide andflap oligonucleotide are hybridized to a target nucleic acid to producea first complex having an overlap as described above. An unpaired “flap”is included on the 5′ end of the flap oligonucleotide. The first complexis a substrate for a flap endonuclease, e.g., a FEN-1 endonuclease,which cleaves the flap oligonucleotide to release the 5′ flap portion.In a secondary reaction, the released 5′ flap product serves as aninvasive oligonucleotide on a FRET cassette to again create thestructure recognized by the flap endonuclease, such that the FRETcassette is cleaved. When the fluorophore and the quencher are separatedby cleavage of the FRET cassette, a detectable fluorescent signal abovebackground fluorescence is produced.

The term “real time” as used herein in reference to detection of nucleicacid amplification or signal amplification refers to the detection ormeasurement of the accumulation of products or signal in the reactionwhile the reaction is in progress, e.g., during incubation or thermalcycling. Such detection or measurement may occur continuously, or it mayoccur at a plurality of discrete points during the progress of theamplification reaction, or it may be a combination. For example, in apolymerase chain reaction, detection (e.g., of fluorescence) may occurcontinuously during all or part of thermal cycling, or it may occurtransiently, at one or more points during one or more cycles. In someembodiments, real time detection of PCR or QUARTS reactions isaccomplished by determining a level of fluorescence at the same point(e.g., a time point in the cycle, or temperature step in the cycle) ineach of a plurality of cycles, or in every cycle. Real time detection ofamplification may also be referred to as detection “during” theamplification reaction.

As used herein, the term “quantitative amplification data set” refers tothe data obtained during quantitative amplification of the targetsample, e.g., target DNA. In the case of quantitative PCR or QuARTSassays, the quantitative amplification data set is a collection offluorescence values obtained at during amplification, e.g., during aplurality of, or all of the thermal cycles. Data for quantitativeamplification is not limited to data collected at any particular pointin a reaction, and fluorescence may be measured at a discrete point ineach cycle or continuously throughout each cycle.

The abbreviations “Ct” and “Cp” as used herein in reference to datacollected during real time PCR and PCR+INVADER assays refer to the cycleat which signal (e.g., fluorescent signal) crosses a predeterminedthreshold value indicative of positive signal. Various methods have beenused to calculate the threshold that is used as a determinant of signalverses concentration, and the value is generally expressed as either the“crossing threshold” (Ct) or the “crossing point” (Cp). Either Cp valuesor Ct values may be used in embodiments of the methods presented hereinfor analysis of real-time signal for the determination of the percentageof variant and/or non-variant constituents in an assay or sample.

As used herein, the term “kit” refers to any delivery system fordelivering materials. In the context of reaction assays, such deliverysystems include systems that allow for the storage, transport, ordelivery of reaction reagents (e.g., oligonucleotides, enzymes, etc. inthe appropriate containers) and/or supporting materials (e.g., buffers,written instructions for performing the assay etc.) from one location toanother. For example, kits include one or more enclosures (e.g., boxes)containing the relevant reaction reagents and/or supporting materials.As used herein, the term “fragmented kit” refers to delivery systemscomprising two or more separate containers that each contains asubportion of the total kit components. The containers may be deliveredto the intended recipient together or separately. For example, a firstcontainer may contain an enzyme for use in an assay, while a secondcontainer contains oligonucleotides.

The term “system” as used herein refers to a collection of articles foruse for a particular purpose. In some embodiments, the articles compriseinstructions for use, as information supplied on e.g., an article, onpaper, or on recordable media (e.g., DVD, CD, flash drive, etc.). Insome embodiments, instructions direct a user to an online location,e.g., a website.

As used herein, the term “information” refers to any collection of factsor data. In reference to information stored or processed using acomputer system(s), including but not limited to internets, the termrefers to any data stored in any format (e.g., analog, digital, optical,etc.). As used herein, the term “information related to a subject”refers to facts or data pertaining to a subject (e.g., a human, plant,or animal). The term “genomic information” refers to informationpertaining to a genome including, but not limited to, nucleic acidsequences, genes, percentage methylation, allele frequencies, RNAexpression levels, protein expression, phenotypes correlating togenotypes, etc. “Allele frequency information” refers to facts or datapertaining to allele frequencies, including, but not limited to, alleleidentities, statistical correlations between the presence of an alleleand a characteristic of a subject (e.g., a human subject), the presenceor absence of an allele in an individual or population, the percentagelikelihood of an allele being present in an individual having one ormore particular characteristics, etc.

DESCRIPTION OF THE DRAWINGS

FIG. 1 shows schematic diagrams of marker target regions in unconvertedform and bisulfite-converted form. Flap assay primers and probes fordetection of bisulfate-converted target DNA are shown.

FIGS. 2-5 provide tables comparing Reduced Representation BisulfiteSequencing (RRBS) results for selecting markers associated with lungcarcinomas as described in Example 2, with each row showing the meanvalues for the indicated marker region (identified by chromosome andstart and stop positions). The ratio of mean methylation for each tissuetype (normal (Norm), adenocarcinoma (Ad), large cell carcinoma (LC),small cell carcinoma(SC), squamous cell carcinoma (SQ) and undefinedcancer (UND)) is compared to the mean methylation of buffy coat samplesfrom normal subjects (WBC or BC)) is shown for each region, and genesand transcripts identified with each region are indicated.

FIG. 2 provides a table comparing RRBS results for selecting markersassociated with lung adenocarcinoma.

FIG. 3 provides a table comparing RRBS results for selecting markersassociated with lung large cell carcinoma.

FIG. 4 provides a table comparing RRBS results for selecting markersassociated with lung small cell carcinoma.

FIG. 5 provides a table comparing RRBS results for selecting markersassociated with lung squamous cell carcinoma.

FIG. 6 provides a table of nucleic acid sequences of assay targets anddetection oligonucleotides, with corresponding SEQ ID NOS.

FIG. 7 provides a graph showing a 6-marker logistic fit of data fromExample 3, using markers SHOX2, SOBP, ZNF781, BTACT, CYP26C1, and DLX4.The ROC curve analysis shows an area under the curve (AUC) of 0.973.

FIG. 8 provides a graph showing a 6-marker logistic fit of data fromExample 3, using markers SHOX2, SOBP, ZNF781, CYP26C1, SUCLG2, and SKI.The ROC curve analysis shows an area under the curve (AUC) of 0.97982.

DETAILED DESCRIPTION OF THE INVENTION

Provided herein is technology relating to selection of nucleic acidmarkers for use in assays for detection and quantification of DNA, e.g.,methylated DNA, and use of the markers in nucleic acid detection assays.In particular, the technology relates to use of methylation assays todetect lung cancer.

In this detailed description of the various embodiments, for purposes ofexplanation, numerous specific details are set forth to provide athorough understanding of the embodiments disclosed. One skilled in theart will appreciate, however, that these various embodiments may bepracticed with or without these specific details. In other instances,structures and devices are shown in block diagram form. Furthermore, oneskilled in the art can readily appreciate that the specific sequences inwhich methods are presented and performed are illustrative and it iscontemplated that the sequences can be varied and still remain withinthe spirit and scope of the various embodiments disclosed herein.

In some embodiments, a marker is a region of 100 or fewer bases, themarker is a region of 500 or fewer bases, the marker is a region of 1000or fewer bases, the marker is a region of 5000 or fewer bases, or, insome embodiments, the marker is one base. In some embodiments the markeris in a high CpG density promoter.

The technology is not limited by sample type. For example, in someembodiments the sample is a stool sample, a tissue sample, sputum, ablood sample (e.g., plasma, serum, whole blood), an excretion, or aurine sample.

Furthermore, the technology is not limited in the method used todetermine methylation state. In some embodiments the assaying comprisesusing methylation specific polymerase chain reaction, nucleic acidsequencing, mass spectrometry, methylation specific nuclease, mass-basedseparation, or target capture. In some embodiments, the assayingcomprises use of a methylation specific oligonucleotide. In someembodiments, the technology uses massively parallel sequencing (e.g.,next-generation sequencing) to determine methylation state, e.g.,sequencing-by-synthesis, real-time (e.g., single-molecule) sequencing,bead emulsion sequencing, nanopore sequencing, etc.

The technology provides reagents for detecting a differentiallymethylated region (DMR). In some embodiments, an oligonucleotide isprovided, the oligonucleotide comprising a sequence complementary to achromosomal region having an annotation selected from BARX1,LOC100129726, SPOCK2, TSC22D4, MAX.chr8.124, RASSFJ, ZNF671, ST8SL41,NKX6_2, FAM59B, DIDO1, MAX_Chr1.110, AGRN, SOBP, MAX_chr10.226, ZMIZ1,MAX_chr8.145, MAX_chr10.225, PRDM14, ANGPT1, MAX.chr16.50, PTGDR_9,ANKRD13B, DOCK2, MAX_chr19.163, ZNF132, MAX chr19.372, HOXA9, TRH, SP9,DMRTA2, ARHGEF4, CYP26C1, ZNF781, PTGDR, GRIN2D, MATK, BCAT1, PRKCB_28,ST8SIA_22, FLJ45983, DLX4, SHOX2, EMX1, HOXB2, MAX.chr12.526, BCL2L11,OPLAH, PARP15, KLHDC7B, SLC12A8, BHLHE23, CAPN2, FGF14, FLJ34208,B3GALT6, BIN2_Z, DNMT3A, FERMT3, NFIX, S1PR4, SKI, SUCLG2, TBX15,ZDHHC1, and ZNF329, preferably to a marker selected from the subsetSLC12A8, KLHDC7B, PARP15, OPLAH, BCL2L11, MAX.chr12.526, HOXB2, EMX1,CYP26C1, SOBP, SUCLG2, SHOX2, ZDHHC1, NFIX, FLJ45983, HOXA9, B3GALT6,ZNF781, SP9, BARX1, and SKI; or a marker selected from any of thesubsets of markers defining the group consisting of ZNF781, BARX1, andEMX1; the group consisting of SHOX2, SOBP, ZNF781, CYP26C1, SUCLG2, andSKI; the group consisting of SLC12A8, KLHDC7B, PARP15, OPLAH, BCL2L11,MAX.chr12.526, HOXB2, and EMX1; the group consisting of SHOX2, SOBP,ZNF781, BTACT, CYP26C1, and DLX4; or the group consisting of SHOX2,SOBP, ZNF781, CYP26C1, SUCLG2, and SKI.

Kit embodiments are provided, e.g., a kit comprising a bisulfatereagent; and a control nucleic acid comprising a chromosomal regionhaving an annotation selected from BARX1, LOC100129726, SPOCK2, TSC22D4,MAX.chr8.124, RASSFL ZNF671, ST8SIA1, NKX6_2, FAM59B, DIDO1,MAX_Chr1.110, AGRN, SOBP, MAX_chr10.226, ZMIZ1, MAX_chr8.145,MAX_chr10.225, PRDM14, ANGPT1, MAX.chr16.50, PTGDR_9, ANKRD13B, DOCK2,MAX_chr19.163, ZNF132, MAX_chr19.372, HOXA9, TRH, SP9, DMRTA2, ARHGEF4,CYP26C1, ZNF781, PTGDR, GRIN2D, MATK, BCAT1, PRKCB_28, ST8SIA_22,FLJ45983, DLX4, SHOX2, EMX1, HOXB2, MAX.chr12.526, BCL2L11, OPLAH,PARP15, KLHDC7B, SLC12A8, BHLHE23, CAPN2, FGF14, FLJ34208, B3GALT6,BIN2_Z, DNMT3A, FERMT3, NFIX, S1PR4, SKI, SUCLG2, TBX15, ZDHHC1, andZNF329, preferably from any of the subsets of markers as recited above,and having a methylation state associated with a subject who does nothave a cancer (e.g., lung cancer). In some embodiments, kits comprise abisulfite reagent and an oligonucleotide as described herein. In someembodiments, kits comprise a bisulfite reagent; and a control nucleicacid comprising a sequence from such a chromosomal region and having amethylation state associated with a subject who has lung cancer.

The technology is related to embodiments of compositions (e.g., reactionmixtures). In some embodiments are provided a composition comprising anucleic acid comprising a chromosomal region having an annotationselected from BARX1, LOC100129726, SPOCK2, TSC22D4, MAX.chr8.124,RASSFJ, ZNF671, ST8SIA1, NKX6_2, FAM59B, DIDO1, MAX_Chr1. 110, AGRN,SOBP, MAX_chr10.226, ZMIZ1, MAX_chr8. 145, MAX_chr10.225, PRDM14,ANGPT1, MAX.chr16.50, PTGDR_9, ANKRD13B, DOCK2, MAX_chr 19. 163, ZNF132,MAX_chr19.372, HOXA9, TRH, SP9, DMRTA2, ARHGEF4, CYP26C1, ZNF781, PTGDR,GRIN2D, MATK, BCAT1, PRKCB_28, ST8SIA_22, FLJ45983, DLX4, SHOX2, EMX1,HOXB2, MAX.chr12.526, BCL2L11, OPLAH, PARP15, KLHDC7B, SLC12A8, BHLHE23,CAPN2, FGF14, FLJ34208, B3GALT6, BIN2_Z, DNMT3A, FERMT3, NFIX, S1PR4,SKI, SUCLG2, TBX15, ZDHHC1, and ZNF329, preferably from any of thesubsets of markers as recited above, and a bisulfite reagent. Someembodiments provide a composition comprising a nucleic acid comprising achromosomal region having an annotation selected from BARX1,LOC100129726, SPOCK2, TSC22D4, MAX.chr8. 124, RASSFL ZNF671, ST8SIA1,NKX6_2, FAM59B, DIDO1, MAX_Chr1.110, AGRN, SOBP, MAX_chr10.226, ZMIZ1,MAX_chr8.145, MAX_chr10.225, PRDM14, ANGPT1, MAX.chr16.50, PTGDR_9,ANKRD13B, DOCK2, MAX_chr19.163, ZNF132, MAX chr19.372, HOXA9, TRH, SP9,DMRTA2, ARHGEF4, CYP26C1, ZNF781, PTGDR, GRIN2D, MATK, BCAT1, PRKCB_28,ST8SIA_22, FLJ45983, DLX4, SHOX2, EMX1, HOXB2, MAX.chr12.526, BCL2L11,OPLAH, PARP15, KLHDC7B, SLC12A8, BHLHE23, CAPN2, FGF14, FLJ34208,B3GALT6, BIN2_Z, DNMT3A, FERMT3, NFIX, S1PR4, SKI, SUCLG2, TBX15,ZDHHC1, and ZNF329, preferably from any of the subsets of markers asrecited above, and an oligonucleotide as described herein. Someembodiments provide a composition comprising a nucleic acid comprising achromosomal region having an annotation selected from BARX1,LOC100129726, SPOCK2, TSC22D4, MAX.chr8. 124, RASSFL ZNF671, ST8SIA1,NKX6_2, FAM59B, DIDO1, MAX_Chr1. 110, AGRN, SOBP, MAX_chr10.226, ZMIZ1,MAX_chr8. 145, MAX_chr10.225, PRDM14, ANGPT1, MAX.chr16.50, PTGDR_9,ANKRD13B, DOCK2, MAX_chr19. 163, ZNF132, MAX chr19.372, HOXA9, TRH, SP9,DMRTA2, ARHGEF4, CYP26C1, ZNF781, PTGDR, GRIN2D, MATK, BCAT1, PRKCB_28,ST8SIA_22, FLJ45983, DLX4, SHOX2, EMX1, HOXB2, MAX.chr12.526, BCL2L11,OPLAH, PARP15, KLHDC7B, SLC12A8, BHLHE23, CAPN2, FGF14, FLJ34208,B3GALT6, BIN2_Z, DNMT3A, FERMT3, NFIX, S1PR4, SKI, SUCLG2, TBX15,ZDHHC1, and ZNF329, preferably from any of the subsets of markers asrecited above, and a methylation-sensitive restriction enzyme. Someembodiments provide a composition comprising a nucleic acid comprising achromosomal region having an annotation selected from BARX1,LOC100129726, SPOCK2, TSC22D4, MAX.chr8. 124, RASSFJ, ZNF671, ST8SIA1,NKX6_2, FAM59B, DIDO1, MAX_Chr 1. 110, AGRN, SOBP, MAX_chr 10.226,ZMIZ1, MAX_chr8. 145, MAX_chr10.225, PRDM14, ANGPT1, MAX.chr16.50,PTGDR_9, ANKRD13B, DOCK2, MAX_chr 19.163, ZNF132, MAX chr19.372, HOXA9,TRH, SP9, DMRTA2, ARHGEF4, CYP26C1, ZNF781, PTGDR, GRIN2D, MATK, BCAT1,PRKCB_28, ST8SIA_22, FLJ45983, DLX4, SHOX2, EMX1, HOXB2, MAX.chr12.526,BCL2L11, OPLAH, PARP15, KLHDC7B, SLC12A8, BHLHE23, CAPN2, FGF14,FLJ34208, B3GALT6, BIN2_Z, DNMT3A, FERMT3, NFIX, S1PR4, SKI, SUCLG2,TBX15, ZDHHC1, and ZNF329, preferably from any of the subsets of markersas recited above, and a polymerase.

Additional related method embodiments are provided for screening for aneoplasm (e.g., lung carcinoma) in a sample obtained from a subject,e.g., a method comprising determining a methylation state of a marker inthe sample comprising a base in a chromosomal region having anannotation selected from BARX1, LOC100129726, SPOCK2, TSC22D4,MAX.chr8.124, RASSFJ, ZNF671, ST8SIA1, NKX6_2, FAM59B, DIDO1, MAX_Chr 1.110, AGRN, SOBP, MAX_chr 10.226, ZMIZ1, MAX_chr8. 145, MAX_chr10.225,PRDM14, ANGPT1, MAX.chr16.50, PTGDR_9, ANKRD13B, DOCK2, MAX_chr 19.163,ZNF132, MAX chr19.372, HOXA9, TRH, SP9, DMRTA2, ARHGEF4, CYP26C1,ZNF781, PTGDR, GRIN2D, MATK, BCAT1, PRKCB_28, ST8SIA_22, FLJ45983, DLX4,SHOX2, EMX1, HOXB2, MAX.chr12.526, BCL2L11, OPLAH, PARP15, KLHDC7B,SLC12A8, BHLHE23, CAPN2, FGF14, FLJ34208, B3GALT6, BIN2_Z, DNMT3A,FERMT3, NFIX, S1PR4, SKI, SUCLG2, TBX15, ZDHHC1, and ZNF329, preferablyfrom any of the subsets of markers as recited above, ; comparing themethylation state of the marker from the subject sample to a methylationstate of the marker from a normal control sample from a subject who doesnot have lung cancer; and determining a confidence interval and/or a pvalue of the difference in the methylation state of the subject sampleand the normal control sample. In some embodiments, the confidenceinterval is 90%, 95%, 97.5%, 98%, 99%, 99.5%, 99.9% or 99.99% and the pvalue is 0.1, 0.05, 0.025, 0.02, 0.01, 0.005, 0.001, or 0.0001. Someembodiments of methods provide steps of reacting a nucleic acidcomprising a chromosomal region having an annotation selected fromBARX1, LOC100129726, SPOCK2, TSC22D4, MAX.chr8. 124, RASSFJ, ZNF671,ST8SIA1, NKX6_2, FAM59B, DIDO1, MAX_Chr1.110, AGRN, SOBP, MAX_chr10.226,ZMIZ1, MAX_chr8. 145, MAX_chr 10.225, PRDM14, ANGPT1, MAX.chr16.50,PTGDR_9, ANKRD13B, DOCK2, MAX_chr19.163, ZNF132, MAX chr19.372, HOXA9,TRH, SP9, DMRTA2, ARHGEF4, CYP26C1, ZNF781, PTGDR, GRIN2D, MATK, BCAT1,PRKCB_28, ST8SIA_22, FLJ45983, DLX4, SHOX2, EMX1, HOXB2, MAX.chr12.526,BCL2L11, OPLAH, PARP15, KLHDC7B, SLC12A8, BHLHE23, CAPN2, FGF14,FLJ34208, B3GALT6, BIN2_Z, DNMT3A, FERMT3, NFIX, S1PR4, SKI, SUCLG2,TBX15, ZDHHC1, and ZNF329, preferably from any of the subsets of markersas recited above, with a bisulfite reagent to produce abisulfite-reacted nucleic acid; sequencing the bisulfite-reacted nucleicacid to provide a nucleotide sequence of the bisulfite-reacted nucleicacid; comparing the nucleotide sequence of the bisulfite-reacted nucleicacid with a nucleotide sequence of a nucleic acid comprising thechromosomal region from a subject who does not have lung cancer toidentify differences in the two sequences; and identifying the subjectas having a neoplasm when a difference is present.

Systems for screening for lung cancer in a sample obtained from asubject are provided by the technology. Exemplary embodiments of systemsinclude, e.g., a system for screening for lung cancer in a sampleobtained from a subject, the system comprising an analysis componentconfigured to determine the methylation state of a sample, a softwarecomponent configured to compare the methylation state of the sample witha control sample or a reference sample methylation state recorded in adatabase, and an alert component configured to alert a user of acancer-associated methylation state. An alert is determined in someembodiments by a software component that receives the results frommultiple assays (e.g., determining the methylation states of multiplemarkers, e.g., a chromosomal region having an annotation selected fromBARU, LOC100129726, SPOCK2, TSC22D4, MAX.chr8.124, RASSFL ZNF671,ST8SIA1, NKX6_2, FAM59B, DIDO1, MAX_Chr 1. 110, AGRN, SOBP,MAX_chr10.226, ZMIZ1, MAX_chr8. 145, MAX_chr 10.225, PRDM14, ANGPT1,MAX.chr16.50, PTGDR_9, ANKRD13B, DOCK2, MAX_chr19.163, ZNF132, MAXchr19.372, HOXA9, TRH, SP9, DMRTA2, ARHGEF4, CYP26C1, ZNF781, PTGDR,GRIN2D, MATK, BCAT1, PRKCB_28, ST8SIA_22, FLJ45983, DLX4, SHOX2, EMX1,HOXB2, MAX.chr12.526, BCL2L11, OPLAH, PARP15, KLHDC7B, SLC12A8, BHLHE23,CAPN2, FGF14, FLJ34208, B3GALT6, BIN2_Z, DNMT3A, FERMT3, NFIX, S1PR4,SKI, SUCLG2, TBX15, ZDHHC1, and ZNF329, preferably from any of thesubsets of markers as recited above, and calculating a value or resultto report based on the multiple results. Some embodiments provide adatabase of weighted parameters associated with each a chromosomalregion having an annotation selected from BARX1, LOC100129726, SPOCK2,TSC22D4, MAX.chr8. 124, RASSFJ, ZNF671, ST8SIA1, NKX6_2, FAM59B, DIDO1,MAX_Chrl. 110, AGRN, SOBP, MAX_chr10.226, ZMIZ1, MAX_chr8. 145, MAX_chr10.225, PRDM14, ANGPT1, MAX.chr16.50, PTGDR_9, ANKRD13B, DOCK2,MAX_chr19.163, ZNF132, MAX chr19.372, HOXA9, TRH, SP9, DMRTA2, ARHGEF4,CYP26C1, ZNF781, PTGDR, GRIN2D, MATK, BCAT1, PRKCB_28, ST8SIA_22,FLJ45983, DLX4, SHOX2, EMX1, HOXB2, MAX.chr12.526, BCL2L11, OPLAH,PARP15, KLHDC7B, SLC12A8, BHLHE23, CAPN2, FGF14, FLJ34208, B3GALT6,BIN2_Z, DNMT3A, FERMT3, NFIX, S1PR4, SKI, SUCLG2, TBX15, ZDHHC1, andZNF329, preferably from any of the subsets of markers as recited above,provided herein for use in calculating a value or result and/or an alertto report to a user (e.g., such as a physician, nurse, clinician, etc.).In some embodiments all results from multiple assays are reported and insome embodiments one or more results are used to provide a score, value,or result based on a composite of one or more results from multipleassays that is indicative of a lung cancer risk in a subject.

In some embodiments of systems, a sample comprises a nucleic acidcomprising a chromosomal region having an annotation selected fromBARX1, LOC100129726, SPOCK2, TSC22D4, MAX.chr8.124, RASSFJ, ZNF671,ST8SIA1, NKX6_2, FAM59B, DIDO1, MAX_Chr 1. 110, AGRN, SOBP, MAX_chr10.226, ZMIZ1, MAX_chr8. 145, MAX_chr10.225, PRDM14, ANGPT1,MAX.chr16.50, PTGDR_9, ANKRD13B, DOCK2, MAX_chr 19. 163, ZNF132,MAX_chr19.372, HOXA9, TRH, SP9, DMRTA2, ARHGEF4, CYP26C1, ZNF781, PTGDR,GRIN2D, MATK, BCAT1, PRKCB_28, ST8SIA_22, FLJ45983, DLX4, SHOX2, EMX1,HOXB2, MAX.chr12.526, BCL2L11, OPLAH, PARP15, KLHDC7B, SLC12A8, BHLHE23,CAPN2, FGF14, FLJ34208, B3GALT6, BIN2_Z, DNMT3A, FERMT3, NFIX, S1PR4,SKI, SUCLG2, TBX15, ZDHHC1, and ZNF329, preferably from any of thesubsets of markers as recited above. In some embodiments the systemfurther comprises a component for isolating a nucleic acid, a componentfor collecting a sample such as a component for collecting a stoolsample. In some embodiments, the system comprises nucleic acid sequencescomprising a chromosomal region having an annotation selected from BARU,LOC100129726, SPOCK2, TSC22D4, MAX.chr8. 124, RASSFL ZNF671, ST8SIA1,NKX6_2, FAM59B, DIDO1, MAX_Chrl. 110, AGRN, SOBP, MAX_chr 10.226, ZMIZ1,MAX_chr8. 145, MAX_chr10.225, PRDM14, ANGPT1, MAX.chr 16.50, PTGDR_9,ANKRD13B, DOCK2, MAX_chr19. 163, ZNF132, MAX_chr 19.372, HOXA9, TRH,SP9, DMRTA2, ARHGEF4, CYP26C1, ZNF781, PTGDR, GRIN2D, MATK, BCAT1,PRKCB_28, ST8SIA_22, FLJ45983, DLX4, SHOX2, EMX1, HOXB2, MAX.chr12.526,BCL2L11, OPLAH, PARP15, KLHDC7B, SLC12A8, BHLHE23, CAPN2, FGF14,FLJ34208, B3GALT6, BIN2_Z, DNMT3A, FERMT3, NFIX, S1PR4, SKI, SUCLG2,TBX15, ZDHHC1, and ZNF329, preferably from any of the subsets of markersas recited above. In some embodiments the database comprises nucleicacid sequences from subjects who do not have lung cancer. Also providedare nucleic acids, e.g., a set of nucleic acids, each nucleic acidhaving a sequence comprising a chromosomal region having an annotationselected from BARX1, LOC100129726, SPOCK2, TSC22D4, MAX.chr8. 124,RASSFJ, ZNF671, ST8SIA1, NKX6_2, FAM59B, DIDO1, MAX_Chr 1. 110, AGRN,SOBP, MAX_chr 10.226, ZMIZ1, MAX_chr8. 145, MAX_chr10.225, PRDM14,ANGPT1, MAX.chr16.50, PTGDR_9, ANKRD13B, DOCK2, MAX_chr 19.163, ZNF132,MAX_chr19.372, HOXA9, TRH, SP9, DMRTA2, ARHGEF4, CYP26C1, ZNF781, PTGDR,GRIN2D, MATK, BCAT1, PRKCB_28, ST8SIA_22, FLJ45983, DLX4, SHOX2, EMX1,HOXB2, MAX.chr12.526, BCL2L11, OPLAH, PARP15, KLHDC7B, SLC12A8, BHLHE23,CAPN2, FGF14, FLJ34208, B3GALT6, BIN2_Z, DNMT3A, FERMT3, NFIX, S1PR4,SKI, SUCLG2, TBX15, ZDHHC1, and ZNF329, preferably from any of thesubsets of markers as recited above.

Related system embodiments comprise a set of nucleic acids as describedand a database of nucleic acid sequences associated with the set ofnucleic acids. Some embodiments further comprise a bisulfate reagent.And, some embodiments further comprise a nucleic acid sequencer.

In certain embodiments, methods for characterizing a sample obtainedfrom a human subject are provided, comprising a) obtaining a sample froma human subject; b) assaying a methylation state of one or more markersin the sample, wherein the marker comprises a base in a chromosomalregion having an annotation selected from the following groups ofmarkers: BARX1, LOC100129726, SPOCK2, TSC22D4, MAX.chr8. 124, RASSFLZNF671, ST8SIA1, NKX6_2, FAM59B, DIDO1, MAX_Chr1.110, AGRN, SOBP,MAX_chr10.226, ZMIZ1, MAX_chr8.145, MAX_chr10.225, PRDM14, ANGPT1,MAX.chr16.50, PTGDR_9, ANKRD13B, DOCK2, MAX_chr19. 163, ZNF132,MAX_chr19.372, HOXA9, TRH, SP9, DMRTA2, ARHGEF4, CYP26C1, ZNF781, PTGDR,GRIN2D, MATK, BCAT1, PRKCB_28, ST8SIA_22, FLJ45983, DLX4, SHOX2, EMXLHOXB2, MAX.chr12. 526, BCL2L11, OPLAH, PARP 15, KLHDC7B, SLC12A8,BHLHE23, CAPN2, FGF14, FLJ34208, B3GALT6, BIN2_Z, DNMT3A, FERMT3, NFIX,S1PR4, SKI, SUCLG2, TBX15, ZDHHC1, and ZNF329, preferably from any ofthe subsets of markers as recited above; and c) comparing themethylation state of the assayed marker to the methylation state of themarker assayed in a subject that does not have a neoplasm.

In some embodiments, the technology is related to assessing the presenceof and methylation state of one or more of the markers identified hereinin a biological sample. These markers comprise one or moredifferentially methylated regions (DMR) as discussed herein. Methylationstate is assessed in embodiments of the technology. As such, thetechnology provided herein is not restricted in the method by which agene's methylation state is measured. For example, in some embodimentsthe methylation state is measured by a genome scanning method. Forexample, one method involves restriction landmark genomic scanning(Kawai et al. (1994) Mol. Cell. Biol. 14: 7421-7427) and another exampleinvolves methylation-sensitive arbitrarily primed PCR (Gonzalgo et al.(1997) Cancer Res. 57: 594-599). In some embodiments, changes inmethylation patterns at specific CpG sites are monitored by digestion ofgenomic DNA with methylation-sensitive restriction enzymes followed bySouthern analysis of the regions of interest (digestion-Southernmethod). In some embodiments, analyzing changes in methylation patternsinvolves a PCR-based process that involves digestion of genomic DNA withmethylation-sensitive restriction enzymes prior to PCR amplification(Singer-Sam et al. (1990) Nucl. Acids Res. 18: 687). In addition, othertechniques have been reported that utilize bisulfate treatment of DNA asa starting point for methylation analysis. These includemethylation-specific PCR (MSP) (Herman et al. (1992) Proc. Natl. Acad.Sci. USA 93: 9821-9826) and restriction enzyme digestion of PCR productsamplified from bisulfite-converted DNA (Sadri and Hornsby (1996) Nucl.Acids Res. 24: 5058-5059; and Xiong and Laird (1997) Nucl. Acids Res.25: 2532-2534). PCR techniques have been developed for detection of genemutations (Kuppuswamy et al. (1991) Proc. Natl. Acad. Sci. USA 88:1143-1147) and quantification of allelic-specific expression (Szabo andMann (1995) Genes Dev. 9: 3097-3108; and Singer-Sam et al. (1992) PCRMethods Appl. 1: 160-163). Such techniques use internal primers, whichanneal to a PCR-generated template and terminate immediately 5′ of thesingle nucleotide to be assayed. Methods using a “quantitative Ms-SNuPEassay” as described in U.S. Pat. No. 7,037,650 are used in someembodiments.

Upon evaluating a methylation state, the methylation state is oftenexpressed as the fraction or percentage of individual strands of DNAthat is methylated at a particular site (e.g., at a single nucleotide,at a particular region or locus, at a longer sequence of interest, e.g.,up to a ˜100-bp, 200-bp, 500-bp, 1000-bp subsequence of a DNA or longer)relative to the total population of DNA in the sample comprising thatparticular site. Traditionally, the amount of the unmethylated nucleicacid is determined by PCR using calibrators. Then, a known amount of DNAis bisulfite treated and the resulting methylation-specific sequence isdetermined using either a real-time PCR or other exponentialamplification, e.g., a QuARTS assay (e.g., as provided by U.S. Pat. Nos.8,361,720; 8,715,937; 8,916,344; and 9,212,392).

For example, in some embodiments methods comprise generating a standardcurve for the unmethylated target by using external standards. Thestandard curve is constructed from at least two points and relates thereal-time Ct value for unmethylated DNA to known quantitative standards.Then, a second standard curve for the methylated target is constructedfrom at least two points and external standards. This second standardcurve relates the Ct for methylated DNA to known quantitative standards.Next, the test sample Ct values are determined for the methylated andunmethylated populations and the genomic equivalents of DNA arecalculated from the standard curves produced by the first two steps. Thepercentage of methylation at the site of interest is calculated from theamount of methylated DNAs relative to the total amount of DNAs in thepopulation, e.g., (number of methylated DNAs)/(the number of methylatedDNAs + number of unmethylated DNAs)×100.

Also provided herein are compositions and kits for practicing themethods. For example, in some embodiments, reagents (e.g., primers,probes) specific for one or more markers are provided alone or in sets(e.g., sets of primers pairs for amplifying a plurality of markers).Additional reagents for conducting a detection assay may also beprovided (e.g., enzymes, buffers, positive and negative controls forconducting QuARTS, PCR, sequencing, bisulfite, or other assays). In someembodiments, the kits containing one or more reagent necessary,sufficient, or useful for conducting a method are provided. Alsoprovided are reactions mixtures containing the reagents. Furtherprovided are master mix reagent sets containing a plurality of reagentsthat may be added to each other and/or to a test sample to complete areaction mixture.

Methods for isolating DNA suitable for these assay technologies areknown in the art. In particular, some embodiments comprise isolation ofnucleic acids as described in U.S. patent application Ser. No.13/470,251 (“Isolation of Nucleic Acids”), incorporated herein byreference in its entirety.

Genomic DNA may be isolated by any means, including the use ofcommercially available kits. Briefly, wherein the DNA of interest isencapsulated by a cellular membrane the biological sample must bedisrupted and lysed by enzymatic, chemical or mechanical means. The DNAsolution may then be cleared of proteins and other contaminants, e.g.,by digestion with proteinase K. The genomic DNA is then recovered fromthe solution. This may be carried out by means of a variety of methodsincluding salting out, organic extraction, or binding of the DNA to asolid phase support. The choice of method will be affected by severalfactors including time, expense, and required quantity of DNA. Allclinical sample types comprising neoplastic matter or pre-neoplasticmatter are suitable for use in the present method, e.g., cell lines,histological slides, biopsies, paraffin-embedded tissue, body fluids,stool, colonic effluent, urine, blood plasma, blood serum, whole blood,isolated blood cells, cells isolated from the blood, and combinationsthereof.

The technology is not limited in the methods used to prepare the samplesand provide a nucleic acid for testing. For example, in someembodiments, a DNA is isolated from a stool sample or from blood or froma plasma sample using direct gene capture, e.g., as detailed in U.S.Pat. Appl. Ser. No. 61/485386 or by a related method.

The technology relates to the analysis of any sample that may beassociated with lung cancer, or that may be examined to establish theabsence of lung cancer. For example, in some embodiments the samplecomprises a tissue and/or biological fluid obtained from a patient. Insome embodiments, the sample comprises a secretion. In some embodiments,the sample comprises sputum, blood, serum, plasma, gastric secretions,lung tissue samples, lung cells or lung DNA recovered from stool. Insome embodiments, the subject is human. Such samples can be obtained byany number of means known in the art, such as will be apparent to theskilled person.

I. Methylation Assays to Detect Lung Cancer

Candidate methylated DNA markers were identified by unbiased wholemethylome sequencing of selected lung cancer case and lung controltissues. The top marker candidates were further evaluated in 255independent patients with 119 controls, of which 37 were from benignnodules, and 136 cases inclusive of all lung cancer subtypes. DNAextracted from patient tissue samples was bisulfite treated and thencandidate markers and β-actin (ACTB) as a normalizing gene were assayedby Quantitative Allele-Specific Real-time Target and Signalamplification (QUARTS amplification). QuARTS assay chemistry yields highdiscrimination for methylated marker selection and screening.

On receiver operator characteristics analyses of individual markercandidates, areas under the curve (AUCs) ranged from 0.512 to 0.941. At100% specificity, a combined panel of 8 methylation markers (SLC12A8,KLHDC7B, PARP15, OPLAH, BCL2L11, MAX 12.526, HOXB2, and EMX1) yielded asensitivity of 98.5% across all subtypes of lung cancer. Furthermore,using the 8 markers panel, benign lung nodules yielded no falsepositives.

II. Methylation Detection Assays and Kits

The markers described herein find use in a variety of methylationdetection assays. The most frequently used method for analyzing anucleic acid for the presence of 5-methylcytosine is based upon thebisulfite method described by Frommer, et al. for the detection of5-methylcytosines in DNA (Frommer et al. (1992) Proc. Natl. Acad. Sci.USA 89: 1827-31 explicitly incorporated herein by reference in itsentirety for all purposes) or variations thereof. The bisulfite methodof mapping 5-methylcytosines is based on the observation that cytosine,but not 5-methylcytosine, reacts with hydrogen sulfite ion (also knownas bisulfite). The reaction is usually performed according to thefollowing steps: first, cytosine reacts with hydrogen sulfite to form asulfonated cytosine. Next, spontaneous deamination of the sulfonatedreaction intermediate results in a sulfonated uracil. Finally, thesulfonated uracil is desulfonated under alkaline conditions to formuracil. Detection is possible because uracil base pairs with adenine(thus behaving like thymine), whereas 5-methylcytosine base pairs withguanine (thus behaving like cytosine). This makes the discrimination ofmethylated cytosines from non-methylated cytosines possible by, e.g.,bisulfite genomic sequencing (Grigg G, & Clark S, Bioessays (1994) 16:431-36; Grigg G, DNA Seq. (1996) 6: 189-98),methylation-specific PCR(MSP) as is disclosed, e.g., in U.S. Pat. No. 5,786,146, or using anassay comprising sequence-specific probe cleavage, e.g., a QuARTS flapendonuclease assay (see, e.g., Zou et al. (2010) “Sensitivequantification of methylated markers with a novel methylation specifictechnology” Clin Chem 56: A199; and in U.S. Pat. Nos. 8,361,720;8,715,937; 8,916,344; and 9,212,392.

Some conventional technologies are related to methods comprisingenclosing the DNA to be analyzed in an agarose matrix, therebypreventing the diffusion and renaturation of the DNA (bisulfite onlyreacts with single-stranded DNA), and replacing precipitation andpurification steps with a fast dialysis (Olek A, et al. (1996) “Amodified and improved method for bisulfite based cytosine methylationanalysis” Nucleic Acids Res. 24: 5064-6). It is thus possible to analyzeindividual cells for methylation status, illustrating the utility andsensitivity of the method. An overview of conventional methods fordetecting 5-methylcytosine is provided by Rein, T., et al. (1998)Nucleic Acids Res. 26: 2255.

The bisulfite technique typically involves amplifying short, specificfragments of a known nucleic acid subsequent to a bisulfite treatment,then either assaying the product by sequencing (Olek & Walter (1997)Nat. Genet. 17: 275-6) or a primer extension reaction (Gonzalgo & Jones(1997) Nucleic Acids Res. 25: 2529-31; WO 95/00669; U.S. Pat. No.6,251,594) to analyze individual cytosine positions. Some methods useenzymatic digestion (Xiong & Laird (1997) Nucleic Acids Res. 25:2532-4). Detection by hybridization has also been described in the art(Olek et al., WO 99/28498). Additionally, use of the bisulfite techniquefor methylation detection with respect to individual genes has beendescribed (Grigg & Clark (1994) Bioessays 16: 431-6; Zeschnigk et al.(1997) Hum Mol Genet. 6: 387-95; Feil et al. (1994) Nucleic Acids Res.22: 695; Martin et al. (1995) Gene 157: 261-4; WO 9746705; WO 9515373).

Various methylation assay procedures can be used in conjunction withbisulfite treatment according to the present technology. These assaysallow for determination of the methylation state of one or a pluralityof CpG dinucleotides (e.g., CpG islands) within a nucleic acid sequence.Such assays involve, among other techniques, sequencing ofbisulfite-treated nucleic acid, PCR (for sequence-specificamplification), Southern blot analysis, and use of methylation-sensitiverestriction enzymes.

For example, genomic sequencing has been simplified for analysis ofmethylation patterns and 5-methylcytosine distributions by usingbisulfite treatment (Frommer et al. (1992) Proc. Natl. Acad. Sci. USA89: 1827-1831). Additionally, restriction enzyme digestion of PCRproducts amplified from bisulfite-converted DNA finds use in assessingmethylation state, e.g., as described by Sadri & Hornsby (1997) Nucl.Acids Res. 24: 5058-5059 or as embodied in the method known as COBRA(Combined Bisulfite Restriction Analysis) (Xiong & Laird (1997) NucleicAcids Res. 25: 2532-2534).

COBRA™ analysis is a quantitative methylation assay useful fordetermining DNA methylation levels at specific loci in small amounts ofgenomic DNA (Xiong & Laird, Nucleic Acids Res. 25:2532-2534, 1997).Briefly, restriction enzyme digestion is used to revealmethylation-dependent sequence differences in PCR products of sodiumbisulfite-treated DNA. Methylation-dependent sequence differences arefirst introduced into the genomic DNA by standard bisulfite treatmentaccording to the procedure described by Frommer et al. (Proc. Natl.Acad. Sci. USA 89:1827-1831, 1992). PCR amplification of the bisulfiteconverted DNA is then performed using primers specific for the CpGislands of interest, followed by restriction endonuclease digestion, gelelectrophoresis, and detection using specific, labeled hybridizationprobes. Methylation levels in the original DNA sample are represented bythe relative amounts of digested and undigested PCR product in alinearly quantitative fashion across a wide spectrum of DNA methylationlevels. In addition, this technique can be reliably applied to DNAobtained from microdissected paraffin-embedded tissue samples.

Typical reagents (e.g., as might be found in a typical COBRA™-based kit)for COBRA™ analysis may include, but are not limited to: PCR primers forspecific loci (e.g., specific genes, markers, regions of genes, regionsof markers, bisulfite treated DNA sequence, CpG island, etc.);restriction enzyme and appropriate buffer; gene-hybridizationoligonucleotide; control hybridization oligonucleotide; kinase labelingkit for oligonucleotide probe; and labeled nucleotides. Additionally,bisulfite conversion reagents may include: DNA denaturation buffer;sulfonation buffer; DNA recovery reagents or kits (e.g., precipitation,ultrafiltration, affinity column); desulfonation buffer; and DNArecovery components.

Assays such as “MethyLight™” (a fluorescence-based real-time PCRtechnique) (Eads et al., Cancer Res. 59:2302-2306, 1999), Ms-SNuPE™(Methylation-sensitive Single Nucleotide Primer Extension) reactions(Gonzalgo & Jones, Nucleic Acids Res. 25:2529-2531, 1997),methylation-specific PCR (“MSP”; Herman et al., Proc. Natl. Acad. Sci.USA 93:9821-9826, 1996; U.S. Pat. No. 5,786,146), and methylated CpGisland amplification (“MCA”; Toyota et al., Cancer Res. 59:2307-12,1999) are used alone or in combination with one or more of thesemethods.

The “HeavyMethyl™” assay, technique is a quantitative method forassessing methylation differences based on methylation-specificamplification of bisulfite-treated DNA. Methylation-specific blockingprobes (“blockers”) covering CpG positions between, or covered by, theamplification primers enable methylation-specific selectiveamplification of a nucleic acid sample.

The term “HeavyMethyl™ MethyLight™” assay refers to a HeavyMethyl™MethyLight™ assay, which is a variation of the MethyLight™ assay,wherein the MethyLight™ assay is combined with methylation specificblocking probes covering CpG positions between the amplificationprimers. The HeavyMethyl™ assay may also be used in combination withmethylation specific amplification primers.

Typical reagents (e.g., as might be found in a typical MethyLight™-basedkit) for HeavyMethyl™ analysis may include, but are not limited to: PCRprimers for specific loci (e.g., specific genes, markers, regions ofgenes, regions of markers, bisulfite treated DNA sequence, CpG island,or bisulfite treated DNA sequence or CpG island, etc.); blockingoligonucleotides; optimized PCR buffers and deoxynucleotides; and Taqpolymerase.

MSP (methylation-specific PCR) allows for assessing the methylationstatus of virtually any group of CpG sites within a CpG island,independent of the use of methylation-sensitive restriction enzymes(Herman et al. Proc. Natl. Acad. Sci. USA 93:9821-9826, 1996; U.S. Pat.No. 5,786,146). Briefly, DNA is modified by sodium bisulfite, whichconverts unmethylated, but not methylated cytosines, to uracil, and theproducts are subsequently amplified with primers specific for methylatedversus unmethylated DNA. MSP requires only small quantities of DNA, issensitive to 0.1% methylated alleles of a given CpG island locus, andcan be performed on DNA extracted from paraffin-embedded samples.Typical reagents (e.g., as might be found in a typical MSP-based kit)for MSP analysis may include, but are not limited to: methylated andunmethylated PCR primers for specific loci (e.g., specific genes,markers, regions of genes, regions of markers, bisulfite treated DNAsequence, CpG island, etc.); optimized PCR buffers and deoxynucleotides,and specific probes.

The MethyLight™ assay is a high-throughput quantitative methylationassay that utilizes fluorescence-based real-time PCR (e.g., TaqMan0)that requires no further manipulations after the PCR step (Eads et al.,Cancer Res. 59:2302-2306, 1999). Briefly, the MethyLight™ process beginswith a mixed sample of genomic DNA that is converted, in a sodiumbisulfite reaction, to a mixed pool of methylation-dependent sequencedifferences according to standard procedures (the bisulfite processconverts unmethylated cytosine residues to uracil). Fluorescence-basedPCR is then performed in a “biased” reaction, e.g., with PCR primersthat overlap known CpG dinucleotides. Sequence discrimination occursboth at the level of the amplification process and at the level of thefluorescence detection process.

The MethyLight™ assay is used as a quantitative test for methylationpatterns in a nucleic acid, e.g., a genomic DNA sample, wherein sequencediscrimination occurs at the level of probe hybridization. In aquantitative version, the PCR reaction provides for a methylationspecific amplification in the presence of a fluorescent probe thatoverlaps a particular putative methylation site. An unbiased control forthe amount of input DNA is provided by a reaction in which neither theprimers, nor the probe, overlie any CpG dinucleotides. Alternatively, aqualitative test for genomic methylation is achieved by probing thebiased PCR pool with either control oligonucleotides that do not coverknown methylation sites (e.g., a fluorescence-based version of theHeavyMethyl™ and MSP techniques) or with oligonucleotides coveringpotential methylation sites.

The MethyLight™ process is used with any suitable probe (e.g. a“TaqMan®” probe, a Lightcycler® probe, etc.) For example, in someapplications double-stranded genomic DNA is treated with sodiumbisulfite and subjected to one of two sets of PCR reactions usingTaqMan® probes, e.g., with MSP primers and/or HeavyMethyl blockeroligonucleotides and a TaqMan® probe. The TaqMan® probe is dual-labeledwith fluorescent “reporter” and “quencher” molecules and is designed tobe specific for a relatively high GC content region so that it melts atabout a 10° C. higher temperature in the PCR cycle than the forward orreverse primers. This allows the TaqMan® probe to remain fullyhybridized during the PCR annealing/extension step. As the Taqpolymerase enzymatically synthesizes a new strand during PCR, it willeventually reach the annealed TaqMan® probe. The Taq polymerase 5′ to 3′endonuclease activity will then displace the TaqMan® probe by digestingit to release the fluorescent reporter molecule for quantitativedetection of its now unquenched signal using a real-time fluorescentdetection system.

Typical reagents (e.g., as might be found in a typical MethyLight™-basedkit) for MethyLight™ analysis may include, but are not limited to: PCRprimers for specific loci (e.g., specific genes, markers, regions ofgenes, regions of markers, bisulfite treated DNA sequence, CpG island,etc.); TaqMan® or Lightcycler® probes; optimized PCR buffers anddeoxynucleotides; and Taq polymerase.

The QM™ (quantitative methylation) assay is an alternative quantitativetest for methylation patterns in genomic DNA samples, wherein sequencediscrimination occurs at the level of probe hybridization. In thisquantitative version, the PCR reaction provides for unbiasedamplification in the presence of a fluorescent probe that overlaps aparticular putative methylation site. An unbiased control for the amountof input DNA is provided by a reaction in which neither the primers, northe probe, overlie any CpG dinucleotides. Alternatively, a qualitativetest for genomic methylation is achieved by probing the biased PCR poolwith either control oligonucleotides that do not cover known methylationsites (a fluorescence-based version of the HeavyMethyl™ and MSPtechniques) or with oligonucleotides covering potential methylationsites.

The QM™ process can be used with any suitable probe, e.g., “TaqMan®”probes, Lightcycler® probes, in the amplification process. For example,double-stranded genomic DNA is treated with sodium bisulfite andsubjected to unbiased primers and the TaqMan® probe. The TaqMan® probeis dual-labeled with fluorescent “reporter” and “quencher” molecules,and is designed to be specific for a relatively high GC content regionso that it melts out at about a 10° C. higher temperature in the PCRcycle than the forward or reverse primers. This allows the TaqMan® probeto remain fully hybridized during the PCR annealing/extension step. Asthe Taq polymerase enzymatically synthesizes a new strand during PCR, itwill eventually reach the annealed TaqMan® probe. The Taq polymerase 5′to 3′ endonuclease activity will then displace the TaqMan® probe bydigesting it to release the fluorescent reporter molecule forquantitative detection of its now unquenched signal using a real-timefluorescent detection system. Typical reagents (e.g., as might be foundin a typical QM™-based kit) for QM™ analysis may include, but are notlimited to: PCR primers for specific loci (e.g., specific genes,markers, regions of genes, regions of markers, bisulfite treated DNAsequence, CpG island, etc.); TaqMan® or Lightcycler® probes; optimizedPCR buffers and deoxynucleotides; and Taq polymerase.

The Ms-SNuPE™ technique is a quantitative method for assessingmethylation differences at specific CpG sites based on bisulfitetreatment of DNA, followed by single-nucleotide primer extension(Gonzalgo & Jones, Nucleic Acids Res. 25:2529-2531, 1997). Briefly,genomic DNA is reacted with sodium bisulfite to convert unmethylatedcytosine to uracil while leaving 5-methylcytosine unchanged.Amplification of the desired target sequence is then performed using PCRprimers specific for bisulfite-converted DNA, and the resulting productis isolated and used as a template for methylation analysis at the CpGsite of interest. Small amounts of DNA can be analyzed (e.g.,microdissected pathology sections) and it avoids utilization ofrestriction enzymes for determining the methylation status at CpG sites.

Typical reagents (e.g., as might be found in a typical Ms-SNuPE™-basedkit) for Ms-SNuPE™ analysis may include, but are not limited to: PCRprimers for specific loci (e.g., specific genes, markers, regions ofgenes, regions of markers, bisulfite treated DNA sequence, CpG island,etc.); optimized PCR buffers and deoxynucleotides; gel extraction kit;positive control primers; Ms-SNuPE™ primers for specific loci; reactionbuffer (for the Ms-SNuPE reaction); and labeled nucleotides.Additionally, bisulfite conversion reagents may include: DNAdenaturation buffer; sulfonation buffer; DNA recovery reagents or kit(e.g., precipitation, ultrafiltration, affinity column); desulfonationbuffer; and DNA recovery components.

Reduced Representation Bisulfite Sequencing (RRBS) begins with bisulfitetreatment of nucleic acid to convert all unmethylated cytosines touracil, followed by restriction enzyme digestion (e.g., by an enzymethat recognizes a site including a CG sequence such as Mspl) andcomplete sequencing of fragments after coupling to an adapter ligand.The choice of restriction enzyme enriches the fragments for CpG denseregions, reducing the number of redundant sequences that may map tomultiple gene positions during analysis. As such, RRBS reduces thecomplexity of the nucleic acid sample by selecting a subset (e.g., bysize selection using preparative gel electrophoresis) of restrictionfragments for sequencing. As opposed to whole-genome bisulfitesequencing, every fragment produced by the restriction enzyme digestioncontains DNA methylation information for at least one CpG dinucleotide.As such, RRBS enriches the sample for promoters, CpG islands, and othergenomic features with a high frequency of restriction enzyme cut sitesin these regions and thus provides an assay to assess the methylationstate of one or more genomic loci.

A typical protocol for RRBS comprises the steps of digesting a nucleicacid sample with a restriction enzyme such as Mspl, filling in overhangsand A-tailing, ligating adaptors, bisulfite conversion, and PCR. See,e.g., et al. (2005) “Genome-scale DNA methylation mapping of clinicalsamples at single-nucleotide resolution” Nat Methods 7: 133-6; Meissneret al. (2005) “Reduced representation bisulfite sequencing forcomparative high-resolution DNA methylation analysis” Nucleic Acids Res.33: 5868-77.

In some embodiments, a quantitative allele-specific real-time target andsignal amplification (QUARTS) assay is used to evaluate methylationstate. Three reactions sequentially occur in each QuARTS assay,including amplification (reaction 1) and target probe cleavage (reaction2) in the primary reaction; and FRET cleavage and fluorescent signalgeneration (reaction 3) in the secondary reaction. When target nucleicacid is amplified with specific primers, a specific detection probe witha flap sequence loosely binds to the amplicon. The presence of thespecific invasive oligonucleotide at the target binding site causes a 5′nuclease, e.g., a FEN-1 endonuclease, to release the flap sequence bycutting between the detection probe and the flap sequence. The flapsequence is complementary to a non-hairpin portion of a correspondingFRET cassette. Accordingly, the flap sequence functions as an invasiveoligonucleotide on the FRET cassette and effects a cleavage between theFRET cassette fluorophore and a quencher, which produces a fluorescentsignal. The cleavage reaction can cut multiple probes per target andthus release multiple fluorophore per flap, providing exponential signalamplification. QuARTS can detect multiple targets in a single reactionwell by using FRET cassettes with different dyes. See, e.g., in Zou etal. (2010) “Sensitive quantification of methylated markers with a novelmethylation specific technology” Clin Chem 56: A199), and U.S. Pat. Nos.8,361,720; 8,715,937; 8,916,344; and 9,212,392, each of which isincorporated herein by reference for all purposes.

In some embodiments, the bisulfite-treated DNA is purified prior to thequantification. This may be conducted by any means known in the art,such as but not limited to ultrafiltration, e.g., by means of Microcon™columns (manufactured by Millipore™). The purification is carried outaccording to a modified manufacturer's protocol (see, e.g.,PCT/EP2004/011715, which is incorporated by reference in its entirety).In some embodiments, the bisulfate treated DNA is bound to a solidsupport, e.g., a magnetic bead, and desulfonation and washing occurswhile the DNA is bound to the support. Examples of such embodiments areprovided, e.g., in WO 2013/116375 and U.S. Pat. No. 9,315,853. Incertain preferred embodiments, support-bound DNA is ready for amethylation assay immediately after desulfonation and washing on thesupport. In some embodiments, the desulfonated DNA is eluted from thesupport prior to assay.

In some embodiments, fragments of the treated DNA are amplified usingsets of primer oligonucleotides according to the present invention(e.g., see FIG. 1) and an amplification enzyme. The amplification ofseveral DNA segments can be carried out simultaneously in one and thesame reaction vessel. Typically, the amplification is carried out usinga polymerase chain reaction (PCR).

Methods for isolating DNA suitable for these assay technologies areknown in the art. In particular, some embodiments comprise isolation ofnucleic acids as described in U.S. Pat. Nos. 9,000,146 and 9,163,278,each incorporated herein by reference in its entirety.

In some embodiments, the markers described herein find use in QUARTSassays performed on stool samples. In some embodiments, methods forproducing DNA samples and, in particular, to methods for producing DNAsamples that comprise highly purified, low-abundance nucleic acids in asmall volume (e.g., less than 100, less than 60 microliters) and thatare substantially and/or effectively free of substances that inhibitassays used to test the DNA samples (e.g., PCR, INVADER, QuARTS assays,etc.) are provided. Such DNA samples find use in diagnostic assays thatqualitatively detect the presence of, or quantitatively measure theactivity, expression, or amount of, a gene, a gene variant (e.g., anallele), or a gene modification (e.g., methylation) present in a sampletaken from a patient. For example, some cancers are correlated with thepresence of particular mutant alleles or particular methylation states,and thus detecting and/or quantifying such mutant alleles or methylationstates has predictive value in the diagnosis and treatment of cancer.

Many valuable genetic markers are present in extremely low amounts insamples and many of the events that produce such markers are rare.Consequently, even sensitive detection methods such as PCR require alarge amount of DNA to provide enough of a low-abundance target to meetor supersede the detection threshold of the assay. Moreover, thepresence of even low amounts of inhibitory substances compromise theaccuracy and precision of these assays directed to detecting such lowamounts of a target. Accordingly, provided herein are methods providingthe requisite management of volume and concentration to produce such DNAsamples.

In some embodiments, the sample comprises blood, serum, plasma, orsaliva. In some embodiments, the subject is human. Such samples can beobtained by any number of means known in the art, such as will beapparent to the skilled person. Cell free or substantially cell freesamples can be obtained by subjecting the sample to various techniquesknown to those of skill in the art which include, but are not limitedto, centrifugation and filtration. Although it is generally preferredthat no invasive techniques are used to obtain the sample, it still maybe preferable to obtain samples such as tissue homogenates, tissuesections, and biopsy specimens. The technology is not limited in themethods used to prepare the samples and provide a nucleic acid fortesting. For example, in some embodiments, a DNA is isolated from astool sample or from blood or from a plasma sample using direct genecapture, e.g., as detailed in U.S. Pat. Nos. 8,808,990 and 9,169,511,and in WO 2012/155072, or by a related method.

The analysis of markers can be carried out separately or simultaneouslywith additional markers within one test sample. For example, severalmarkers can be combined into one test for efficient processing ofmultiple samples and for potentially providing greater diagnostic and/orprognostic accuracy. In addition, one skilled in the art would recognizethe value of testing multiple samples (for example, at successive timepoints) from the same subject. Such testing of serial samples can allowthe identification of changes in marker methylation states over time.Changes in methylation state, as well as the absence of change inmethylation state, can provide useful information about the diseasestatus that includes, but is not limited to, identifying the approximatetime from onset of the event, the presence and amount of salvageabletissue, the appropriateness of drug therapies, the effectiveness ofvarious therapies, and identification of the subject's outcome,including risk of future events.

The analysis of biomarkers can be carried out in a variety of physicalformats. For example, the use of microtiter plates or automation can beused to facilitate the processing of large numbers of test samples.Alternatively, single sample formats could be developed to facilitateimmediate treatment and diagnosis in a timely fashion, for example, inambulatory transport or emergency room settings.

It is contemplated that embodiments of the technology are provided inthe form of a kit. The kits comprise embodiments of the compositions,devices, apparatuses, etc. described herein, and instructions for use ofthe kit. Such instructions describe appropriate methods for preparing ananalyte from a sample, e.g., for collecting a sample and preparing anucleic acid from the sample. Individual components of the kit arepackaged in appropriate containers and packaging (e.g., vials, boxes,blister packs, ampules, jars, bottles, tubes, and the like) and thecomponents are packaged together in an appropriate container (e.g., abox or boxes) for convenient storage, shipping, and/or use by the userof the kit. It is understood that liquid components (e.g., a buffer) maybe provided in a lyophilized form to be reconstituted by the user. Kitsmay include a control or reference for assessing, validating, and/orassuring the performance of the kit. For example, a kit for assaying theamount of a nucleic acid present in a sample may include a controlcomprising a known concentration of the same or another nucleic acid forcomparison and, in some embodiments, a detection reagent (e.g., aprimer) specific for the control nucleic acid. The kits are appropriatefor use in a clinical setting and, in some embodiments, for use in auser's home. The components of a kit, in some embodiments, provide thefunctionalities of a system for preparing a nucleic acid solution from asample. In some embodiments, certain components of the system areprovided by the user.

III. Applications

In some embodiments, diagnostic assays identify the presence of adisease or condition in an individual. In some embodiments, the diseaseis cancer (e.g., lung cancer). In some embodiments, markers whoseaberrant methylation is associated with a lung cancer (e.g., one or moremarkers selected from the markers listed in Table 1, or preferably oneor more of BARX1, LOC100129726, SPOCK2, TSC22D4, MAX.chr8.124, RASSFJ,ZNF671, ST8SIA1, NKX6_2, FAM59B, DIDO1, MAX_Chr1.110, AGRN, SOBP,MAX_chr 1 0.226, ZMIZJ, MAX_chr8.145, MAX_chr10.225, PRDM14, ANGPT1,MAX.chr16.50, PTGDR_9, ANKRD13B, DOCK2, MAX_chr19.163, ZNF132, MAXchr19.372, HOXA9, TRH, SP9, DMRTA2, ARHGEF4, CYP26C1, ZNF781, PTGDR,GRIN2D, MATK, BCAT1, PRKCB_28, ST8SIA_22, FLJ45983, DLX4, SHOX2, EMX1,HOXB2, MAX.chr12.526, BCL2L11, OPLAH, PARP15, KLHDC7B, SLC12A8, BHLHE23,CAPN2, FGF14, FLJ34208, B3GALT6, BIN2_Z, DNMT3A, FERMT3, NFIX, S1PR4,SKI, SUCLG2, TBX15, ZDHHC1, and ZNF329) are used. In some embodiments,an assay further comprises detection of a reference gene (e.g.,(3-actin, ZDHHC1, B3GALT6. See, e.g., U.S. patent application Ser. No.14/966,617, filed Dec. 11, 2015, and U.S. Pat. Appl. No. 62/364,082,filed Jul. 19, 2016, each of which is incorporated herein by referencefor all purposes).

In some embodiments, the technology finds application in treating apatient (e.g., a patient with lung cancer, with early stage lung cancer,or who may develop lung cancer), the method comprising determining themethylation state of one or more markers as provided herein andadministering a treatment to the patient based on the results ofdetermining the methylation state. The treatment may be administrationof a pharmaceutical compound, a vaccine, performing a surgery, imagingthe patient, performing another test. Preferably, said use is in amethod of clinical screening, a method of prognosis assessment, a methodof monitoring the results of therapy, a method to identify patients mostlikely to respond to a particular therapeutic treatment, a method ofimaging a patient or subject, and a method for drug screening anddevelopment.

In some embodiments, the technology finds application in methods fordiagnosing lung cancer in a subject is provided. The terms “diagnosing”and “diagnosis” as used herein refer to methods by which the skilledartisan can estimate and even determine whether or not a subject issuffering from a given disease or condition or may develop a givendisease or condition in the future. The skilled artisan often makes adiagnosis on the basis of one or more diagnostic indicators, such as forexample a biomarker, the methylation state of which is indicative of thepresence, severity, or absence of the condition.

Along with diagnosis, clinical cancer prognosis relates to determiningthe aggressiveness of the cancer and the likelihood of tumor recurrenceto plan the most effective therapy. If a more accurate prognosis can bemade or even a potential risk for developing the cancer can be assessed,appropriate therapy, and in some instances less severe therapy for thepatient can be chosen. Assessment (e.g., determining methylation state)of cancer biomarkers is useful to separate subjects with good prognosisand/or low risk of developing cancer who will need no therapy or limitedtherapy from those more likely to develop cancer or suffer a recurrenceof cancer who might benefit from more intensive treatments.

As such, “making a diagnosis” or “diagnosing”, as used herein, isfurther inclusive of making determining a risk of developing cancer ordetermining a prognosis, which can provide for predicting a clinicaloutcome (with or without medical treatment), selecting an appropriatetreatment (or whether treatment would be effective), or monitoring acurrent treatment and potentially changing the treatment, based on themeasure of the diagnostic biomarkers disclosed herein.

Further, in some embodiments of the technology, multiple determinationsof the biomarkers over time can be made to facilitate diagnosis and/orprognosis. A temporal change in the biomarker can be used to predict aclinical outcome, monitor the progression of lung cancer, and/or monitorthe efficacy of appropriate therapies directed against the cancer. Insuch an embodiment for example, one might expect to see a change in themethylation state of one or more biomarkers disclosed herein (andpotentially one or more additional biomarker(s), if monitored) in abiological sample over time during the course of an effective therapy.

The technology further finds application in methods for determiningwhether to initiate or continue prophylaxis or treatment of a cancer ina subject. In some embodiments, the method comprises providing a seriesof biological samples over a time period from the subject; analyzing theseries of biological samples to determine a methylation state of atleast one biomarker disclosed herein in each of the biological samples;and comparing any measurable change in the methylation states of one ormore of the biomarkers in each of the biological samples. Any changes inthe methylation states of biomarkers over the time period can be used topredict risk of developing cancer, predict clinical outcome, determinewhether to initiate or continue the prophylaxis or therapy of thecancer, and whether a current therapy is effectively treating thecancer. For example, a first time point can be selected prior toinitiation of a treatment and a second time point can be selected atsome time after initiation of the treatment. Methylation states can bemeasured in each of the samples taken from different time points andqualitative and/or quantitative differences noted. A change in themethylation states of the biomarker levels from the different samplescan be correlated with risk for developing lung, prognosis, determiningtreatment efficacy, and/or progression of the cancer in the subject.

In preferred embodiments, the methods and compositions of the inventionare for treatment or diagnosis of disease at an early stage, forexample, before symptoms of the disease appear. In some embodiments, themethods and compositions of the invention are for treatment or diagnosisof disease at a clinical stage.

As noted above, in some embodiments multiple determinations of one ormore diagnostic or prognostic biomarkers can be made, and a temporalchange in the marker can be used to determine a diagnosis or prognosis.For example, a diagnostic marker can be determined at an initial time,and again at a second time. In such embodiments, an increase in themarker from the initial time to the second time can be diagnostic of aparticular type or severity of cancer, or a given prognosis. Likewise, adecrease in the marker from the initial time to the second time can beindicative of a particular type or severity of cancer, or a givenprognosis. Furthermore, the degree of change of one or more markers canbe related to the severity of the cancer and future adverse events. Theskilled artisan will understand that, while in certain embodimentscomparative measurements can be made of the same biomarker at multipletime points, one can also measure a given biomarker at one time point,and a second biomarker at a second time point, and a comparison of thesemarkers can provide diagnostic information.

As used herein, the phrase “determining the prognosis” refers to methodsby which the skilled artisan can predict the course or outcome of acondition in a subject. The term “prognosis” does not refer to theability to predict the course or outcome of a condition with 100%accuracy, or even that a given course or outcome is predictably more orless likely to occur based on the methylation state of a biomarker.Instead, the skilled artisan will understand that the term “prognosis”refers to an increased probability that a certain course or outcome willoccur; that is, that a course or outcome is more likely to occur in asubject exhibiting a given condition, when compared to those individualsnot exhibiting the condition. For example, in individuals not exhibitingthe condition, the chance of a given outcome (e.g., suffering from lungcancer) may be very low.

In some embodiments, a statistical analysis associates a prognosticindicator with a predisposition to an adverse outcome. For example, insome embodiments, a methylation state different from that in a normalcontrol sample obtained from a patient who does not have a cancer cansignal that a subject is more likely to suffer from a cancer thansubjects with a level that is more similar to the methylation state inthe control sample, as determined by a level of statisticalsignificance. Additionally, a change in methylation state from abaseline (e.g., “normal”) level can be reflective of subject prognosis,and the degree of change in methylation state can be related to theseverity of adverse events. Statistical significance is often determinedby comparing two or more populations and determining a confidenceinterval and/or ap value. See, e.g., Dowdy and Wearden, Statistics forResearch, John Wiley & Sons, New York, 1983, incorporated herein byreference in its entirety. Exemplary confidence intervals of the presentsubject matter are 90%, 95%, 97.5%, 98%, 99%, 99.5%, 99.9% and 99.99%,while exemplary p values are 0.1, 0.05, 0.025, 0.02, 0.01, 0.005, 0.001,and 0.0001.

In other embodiments, a threshold degree of change in the methylationstate of a prognostic or diagnostic biomarker disclosed herein can beestablished, and the degree of change in the methylation state of thebiomarker in a biological sample is simply compared to the thresholddegree of change in the methylation state. A preferred threshold changein the methylation state for biomarkers provided herein is about 5%,about 10%, about 15%, about 20%, about 25%, about 30%, about 50%, about75%, about 100%, and about 150%. In yet other embodiments, a “nomogram”can be established, by which a methylation state of a prognostic ordiagnostic indicator (biomarker or combination of biomarkers) isdirectly related to an associated disposition towards a given outcome.The skilled artisan is acquainted with the use of such nomograms torelate two numeric values with the understanding that the uncertainty inthis measurement is the same as the uncertainty in the markerconcentration because individual sample measurements are referenced, notpopulation averages.

In some embodiments, a control sample is analyzed concurrently with thebiological sample, such that the results obtained from the biologicalsample can be compared to the results obtained from the control sample.Additionally, it is contemplated that standard curves can be provided,with which assay results for the biological sample may be compared. Suchstandard curves present methylation states of a biomarker as a functionof assay units, e.g., fluorescent signal intensity, if a fluorescentlabel is used. Using samples taken from multiple donors, standard curvescan be provided for control methylation states of the one or morebiomarkers in normal tissue, as well as for “at-risk” levels of the oneor more biomarkers in tissue taken from donors with lung cancer.

The analysis of markers can be carried out separately or simultaneouslywith additional markers within one test sample. For example, severalmarkers can be combined into one test for efficient processing of amultiple of samples and for potentially providing greater diagnosticand/or prognostic accuracy. In addition, one skilled in the art wouldrecognize the value of testing multiple samples (for example, atsuccessive time points) from the same subject. Such testing of serialsamples can allow the identification of changes in marker methylationstates over time. Changes in methylation state, as well as the absenceof change in methylation state, can provide useful information about thedisease status that includes, but is not limited to, identifying theapproximate time from onset of the event, the presence and amount ofsalvageable tissue, the appropriateness of drug therapies, theeffectiveness of various therapies, and identification of the subject'soutcome, including risk of future events.

The analysis of biomarkers can be carried out in a variety of physicalformats. For example, the use of microtiter plates or automation can beused to facilitate the processing of large numbers of test samples.Alternatively, single sample formats could be developed to facilitateimmediate treatment and diagnosis in a timely fashion, for example, inambulatory transport or emergency room settings.

In some embodiments, the subject is diagnosed as having lung cancer if,when compared to a control methylation state, there is a measurabledifference in the methylation state of at least one biomarker in thesample. Conversely, when no change in methylation state is identified inthe biological sample, the subject can be identified as not having lungcancer, not being at risk for the cancer, or as having a low risk of thecancer. In this regard, subjects having lung cancer or risk thereof canbe differentiated from subjects having low to substantially no cancer orrisk thereof Those subjects having a risk of developing lung cancer canbe placed on a more intensive and/or regular screening schedule. On theother hand, those subjects having low to substantially no risk may avoidbeing subjected to screening procedures, until such time as a futurescreening, for example, a screening conducted in accordance with thepresent technology, indicates that a risk of lung cancer has appeared inthose subjects.

As mentioned above, depending on the embodiment of the method of thepresent technology, detecting a change in methylation state of the oneor more biomarkers can be a qualitative determination or it can be aquantitative determination. As such, the step of diagnosing a subject ashaving, or at risk of developing, lung cancer indicates that certainthreshold measurements are made, e.g., the methylation state of the oneor more biomarkers in the biological sample varies from a predeterminedcontrol methylation state. In some embodiments of the method, thecontrol methylation state is any detectable methylation state of thebiomarker. In other embodiments of the method where a control sample istested concurrently with the biological sample, the predeterminedmethylation state is the methylation state in the control sample. Inother embodiments of the method, the predetermined methylation state isbased upon and/or identified by a standard curve. In other embodimentsof the method, the predetermined methylation state is a specificallystate or range of state. As such, the predetermined methylation statecan be chosen, within acceptable limits that will be apparent to thoseskilled in the art, based in part on the embodiment of the method beingpracticed and the desired specificity, etc.

In some embodiments, a sample from a subject having or suspected ofhaving lung cancer is screened using one or more methylation markers andsuitable assay methods that provide data that differentiate betweendifferent types of lung cancer, e.g., non-small cell (adenocarcinoma,large cell carcinoma, squamous cell carcinoma) and small cellcarcinomas. See, e.g., marker ref # AC27 (FIG. 2; PLEC), which is highlymethylated (shown as mean methylation compared to mean methylation atthat locus in normal buffy coat) in adenocarcinoma and small cellcarcinomas, but not in large cell or squamous cell carcinoma; marker ref# AC23 (FIG. 2; ITPRIPL1), which is more highly methylated inadenocarcinoma than in any other sample type; marker ref # LC2 (FIG. 3;DOCK2)), which is more highly methylated in large cell carcinomas thanin any other sample type; marker ref # SC221 (FIG. 4; ST8SIA4), which ismore highly methylated in small cell carcinomas than in any other sampletype; and marker ref # SQ36 (FIG. 5, DOK1), which is more highlymethylated in squamous cell carcinoma than in than in any other sampletype.

Methylation markers selected as described herein may be used alone or incombination (e.g., in panels) such that analysis of a sample from asubject reveals the presence of a lung neoplasm and also providessufficient information to distinguish between lung cancer type, e.g.,small cell carcinoma vs. non-small cell carcinoma. In preferredembodiments, a marker or combination of markers further provide datasufficient to distinguish between adenomcarcinomas, large cellcarcinomas, and squamous cell carcinomas; and/or to characterizecarcinomas of undetermined or mixed pathologies. In other embodiments,methylation markers or combinations thereof are selected to provide apositive result (i.e., a result indicating the presence of lungneoplasm) regardless of the type of lung carcinoma present, withoutdifferentiating data.

Over recent years, it has become apparent that circulating epithelialcells, representing metastatic tumor cells, can be detected in the bloodof many patients with cancer. Molecular profiling of rare cells isimportant in biological and clinical studies. Applications range fromcharacterization of circulating epithelial cells (CEpCs) in theperipheral blood of cancer patients for disease prognosis andpersonalized treatment (See e.g., Cristofanilli M, et al. (2004) N EnglJ Med 351:781-791; Hayes D F, et al. (2006) Clin Cancer Res12:4218-4224; Budd G T, et al., (2006) Clin Cancer Res 12:6403-6409;Moreno J G, et al. (2005) Urology 65:713-718; Pantel et al., (2008) NatRev 8:329-340; and Cohen S J, et al. (2008) J Clin Oncol 26:3213-3221).Accordingly, embodiments of the present disclosure provide compositionsand methods for detecting the presence of metastatic cancer in a subjectby identifying the presence of methylated markers in plasma or wholeblood.

EXPERIMENTAL EXAMPLES Example 1 Sample Preparation Methods Methods forDNA Isolation and QUARTS Assay

The following provides exemplary method for DNA isolation prior toanalysis, and an exemplary QUARTS assay, such as may be used inaccordance with embodiments of the technology. Application of QUARTStechnology to DNA from blood and various tissue samples is described inthis example, but the technology is readily applied to other nucleicacid samples, as shown in other examples.

DNA Isolation From Cells and Plasma

For cell lines, genomic DNA may be isolated from cell conditioned mediausing, for example, the “Maxwell® RSC ccfDNA Plasma Kit (Promega Corp.,Madison, Wis.). Following the kit protocol, 1 mL of cell conditionedmedia (CCM) is used in place of plasma, and processed according to thekit procedure. The elution volume is 100 μL, of which 70 μL aregenerally used for bisulfite conversion.

An exemplary procedure for isolating DNA from a 4 mL sample of plasma isas follows:

-   -   To a 4 mL sample of plasma, 300 μL of Proteinase K (20mg/mL) is        added and mixed.    -   Add 3 μL of 1μg/μL of Fish DNA to the plasma-proteinase K        mixture.    -   Add 2 mL of plasma lysis buffer to plasma.        -   Plasma lysis buffer is:            -   4.3M guanidine thiocyanate            -   10% IGEPAL CA-630 (Octylphenoxy                poly(ethyleneoxy)ethanol, branched)            -   (5.3g of IGEPAL CA-630 combined with 45 mL of 4.8 M                guanidine thiocyanate)    -   Incubate mixtures at 55° C. for 1 hour with shaking at 500 rpm.    -   Add 3 mL of plasma lysis buffer and mix.    -   Add 200 μL magnetic silica binding beads (16 μg of beads/μL} and        mix again.    -   Add 2 mL of 100% isopropanol and mix.    -   Incubate at 30° C. for 30 minutes with shaking at 500 rpm.    -   Place tube(s) on magnet and let the beads collect. Aspirate and        discard the supernatant.    -   Add 750 μL GuHC1-EtOH to vessel containing the binding beads and        mix.        -   GuHCl-EtOH wash buffer is:            -   3M GuHCl (guanidine hydrochloride)            -   57% EtOH (ethyl alcohol)    -   Shake at 400 rpm for 1 minute.    -   Transfer samples to a deep well plate or 2 mL microcentrifuge        tubes.    -   Place tubes on magnet and let the beads collect for 10 minutes.        Aspirate and discard the supernatant.    -   Add 1000 μL wash buffer (10 mM Tris HC1, 80% EtOH) to the beads,        and incubate at 30° C. for 3 minutes with shaking.    -   Place tubes on magnet and let the beads collect. Aspirate and        discard the supernatant.    -   Add 500 μL wash buffer to the beads and incubate at 30° C. for 3        minutes with shaking.    -   Place tubes on magnet and let the beads collect. Aspirate and        discard the supernatant.    -   Add 250 μL wash buffer and incubate at 30° C. for 3 minutes with        shaking.    -   Place tubes on magnet and let the beads collect. Aspirate and        discard the remaining buffer.    -   Add 250 μL wash buffer and incubate at 30° C. for 3 minutes with        shaking.    -   Place tubes on magnet and let the beads collect. Aspirate and        discard the remaining buffer.    -   Dry the beads at 70° C. for 15 minutes, with shaking.    -   Add 125 μL elution buffer (10 mM Tris HC1, pH 8.0, 0.1 mM EDTA)        to the beads and incubate at 65° C. for 25 minutes with shaking.    -   Place tubes on magnet and let the beads collect for 10 minutes.    -   Aspirate and transfer the supernatant containing the DNA to a        new vessel or tube.

Bisulfite Conversion I. Sulfonation of DNA Using Ammonium HydrogenSulfite

-   -   1. In each tube, combine 64 μL DNA, 7μL 1 N NaOH, and 9μL of        carrier solution containing 0.2 mg/mL BSA and 0.25 mg/mL of fish        DNA.    -   2. Incubate at 42° C. for 20 minutes.    -   3. Add 120 μL of 45% ammonium hydrogen sulfite and incubate at        66° for 75 minutes.    -   4. Incubate at 4° C. for 10 minutes.

II. Desulfonation Using Magnetic Beads Materials

-   -   Magnetic beads (Promega MagneSil Paramagnetic Particles, Promega        catalogue number AS1050, 16 μg/μL ).    -   Binding buffer: 6.5-7 M guanidine hydrochoride.    -   Post-conversion Wash buffer: 80% ethanol with 10 mM Tris HCl (pH        8.0).    -   Desulfonation buffer: 70% isopropyl alcohol, 0.1 N NaOH was        selected for the desulfonation buffer.

Samples are mixed using any appropriate device or technology to mix orincubate samples at the temperatures and mixing speeds essentially asdescribed below. For example, a Thermomixer (Eppendorf) can be used forthe mixing or incubation of samples. An exemplary desulfonation is asfollows:

-   1. Mix bead stock thoroughly by vortexing bottle for 1 minute.-   2. Aliquot 50 μL of beads into a 2.0 mL tube (e.g., from USA    Scientific).-   3. Add 750 μL of binding buffer to the beads.-   4. Add 150 μL of sulfonated DNA from step I.-   5. Mix (e.g., 1000 RPM at 30° C. for 30 minutes).-   6. Place tube on the magnet stand and leave in place for 5 minutes.    With the tubes on the stand, remove and discard the supernatant.-   7. Add 1,000 μL of wash buffer. Mix (e.g., 1000 RPM at 30° C. for 3    minutes).-   8. Place tube on the magnet stand and leave in place for 5 minutes.    With the tubes on the stand, remove and discard the supernatant.-   9. Add 250 μL of wash buffer. Mix (e.g., 1000 RPM at 30° C. for 3    minutes).-   10. Place tube on magnetic rack; remove and discard supernatant    after 1 minute.-   11. Add 200 μL of desulfonation buffer. Mix (e.g., 1000 RPM at    30° C. for 5 minutes).-   12. Place tube on magnetic rack; remove and discard supernatant    after 1 minute.-   13. Add 250 μL of wash buffer. Mix (e.g., 1000 RPM at 30° C. for 3    minutes).-   14. Place tube on magnetic rack; remove and discard supernatant    after 1 minute.-   15. Add 250 μL of wash buffer to the tube. Mix (e.g., 1000 RPM at    30° C. for 3 minutes).-   16. Place tube on magnetic rack; remove and discard supernatant    after 1 minute.-   17. Incubate all tubes at 30° C. with the lid open for 15 minutes.-   18. Remove tube from magnetic rack and add 70 μL of elution buffer    directly to the beads.-   19. Incubate the beads with elution-buffer (e.g., 1000 RPM at 40° C.    for 45 minutes).-   20. Place tubes on magnetic rack for about one minute; remove and    save the supernatant.

The converted DNA is then used in a detection assay, e.g., apre-amplification and/or flap endonuclease assays, as described below.

See also U.S. Patent Appl. Ser. Nos. 62/249,097, filed Oct. 30, 2015;U.S. patent application Ser. Nos. 15/335,111 and 15/335,096, both filedOct. 26, 2016; and International Appl. Ser. No. PCT/US16/58875, filedOct. 26, 2016, each of which is incorporated herein by reference in itsentirety, for all purposes.

QuARTS Assay

The QUARTS technology combines a polymerase-based target DNAamplification process with an invasive cleavage-based signalamplification process. The technology is described, e.g., in U.S. Pat.Nos. 8,361,720; 8,715,937; 8,916,344; and 9,212,392, each of which isincorporated herein by reference. Fluorescence signal generated by theQUARTS reaction is monitored in a fashion similar to real-time PCR andpermits quantitation of the amount of a target nucleic acid in a sample.

An exemplary QUARTS reaction typically comprises approximately 400-600 nmol/L (e.g., 500 n mol/L) of each primer and detection probe,approximately 100 n mol/L of the invasive oligonucleotide, approximately600-700 n mol/L of each FRET cassette (FAM, e.g., as suppliedcommercially by Hologic, Inc.; HEX, e.g., as supplied commercially byBioSearch Technologies; and Quasar 670, e.g., as supplied commerciallyby BioSearch Technologies), 6.675 ng/μL FEN-1 endonuclease (e.g.,Cleavase® 2.0, Hologic, Inc.), 1 unit Taq DNA polymerase in a 30 μLreaction volume (e.g., GoTaq® DNA polymerase, Promega Corp., Madison,Wisc.), 10 m mol/L 3-(n-morpholino) propanesulfonic acid (MOPS), 7.5 mmol/L MgCl₂, and 250 μmol/L of each dNTP. Exemplary QUARTS cyclingconditions are as shown in the table below. In some applications,analysis of the quantification cycle (C_(q)) provides a measure of theinitial number of target DNA strands (e.g., copy number) in the sample.

Stage Temp/Time # of Cycles Denaturation 95° C./3′ 1 Amplification 1 95°C./20″ 10 67° C./30″ 70° C./30″ Amplification 2 95° C./20″ 37 53° C./1′70° C./30″ Cooling 40° C./30″ 1

Multiplex Targeted Pre-amplification of Large-Volume Bisulfite-ConvertedDNA

To pre-amplify most or all of the bisulfite-treated DNA from an inputsample, a large volume of the treated DNA may be used in a single,large-volume multiplex amplification reaction. For example, DNA isextracted from a cell lines (e.g., DFCI032 cell line (adenocarcinoma);H1755 cell line (neuroendocrine), using, for example, the MaxwellPromega blood kit # AS1400, as described above. The DNA is bisulfateconverted, e.g., as described above.

A pre-amplification is conducted, for example, in a reaction mixturecontaining 7.5 mM MgCl₂, 10 mM MOPS, 0.3 mM Tris-HC1, pH 8.0, 0.8 mMKC1, 0.1 μg/μL BSA, 0.0001% Tween-20, 0. 0001% IGEPAL CA-630, 250 μMeach dNTP, oligonucleotide primers, (e.g., for 12 targets, 12 primerpairs/24 primers, in equimolar amounts (including but not limited to theranges of, e.g., 200-500 nM each primer), or with individual primerconcentrations adjusted to balance amplification efficiencies of thedifferent target regions), 0.025 units/μL HotStart GoTaq concentration,and 20 to 50% by volume of bisulfate-treated target DNA (e.g., 10 μL oftarget DNA into a 50 μL reaction mixture, or 50 μL of target DNA into a125 μL reaction mixture). Thermal cycling times and temperatures areselected to be appropriate for the volume of the reaction and theamplification vessel. For example, the reactions may be cycled asfollows

Stage Temp/Time #of Cycles Pre-incubation 95° C./5′ 1 Amplification 195° C./30″ 10 64° C./30″ 72° C./30″ Cooling 4° C./Hold 1

After thermal cycling, aliquots of the pre-amplification reaction (e.g.,10 μL) are diluted to 500 μL in 10 mM Tris, 0.1 mM EDTA, with or withoutfish DNA. Aliquots of the diluted pre-amplified DNA (e.g., 10 μL) areused in a QUARTS PCR-flap assay, e.g., as described above. See also U.S.Patent Appl. Ser. No. 62/249,097, filed Oct. 30, 2015; application Ser.No. 15/335,096, filed Oct. 26, 2016, and PCT/US16/58875, filed Oct. 26,2016, each of which is incorporated herein by reference in its entiretyfor all purposes.

Example 2 Selection and Testing of Methylation Markers Marker SelectionProcess:

Reduced Representation Bisulfite Sequencing (RRBS) data was obtained ontissues from 16 adenocarcinoma lung cancer, 11 large cell lung cancer,14 small cell lung cancer, 24 squamous cell lung cancer, and 18non-cancer lung as well as RRBS results of buffy coat samples obtainedfrom 26 healthy patients.

After alignment to a bisulfite-converted form of the human genomesequence, average methylation at each CpG island was computed for eachsample type (i.e., tissue or buffy coat) and marker regions wereselected based on the following criteria:

-   -   Regions were selected to be 50 base pairs or longer.    -   For QUARTS flap assay designs, regions were selected to have a        minimum of 1 methylated CpG under each of: a) the probe        region, b) the forward primer binding region, and c) the reverse        primer binding region. For the forward and reverse primers, it        is preferred that the methylated CpGs are close to the 3′-ends        of the primers, but not at the 3′terminal nucleotide. Exemplary        flap endonuclease assay oligonucleotides are shown in FIG. 1.    -   Preferably, buffy coat methylation at any CpG in a region of        interest is no more than >0.5%.    -   Preferably, cancer tissue methylation in a region of interest is        >10%.    -   For assays designed for tissue analysis, normal tissue        methylation in a region of interest is preferably <0.5%.

RRBS data for different lung cancer tissue types is shown in FIGS. 2-5.Based on the criteria above, the markers shown in the table below wereselected and QuARTS flap assays were designed for them, as shown in FIG.1.

TABLE l Marker Name Genomic coordinates AGRN chr1: 968467-968582, strand= + ANGPT1 chr8: 108509559-108509684, strand = − ANKRD13B chr17:27940470-27940578, strand = + ARHGEF4 chr2: 131792758-131792900, strand= − B3GALT6 chr1: 1163595-1163733, strand = + BARX1 chr9:96721498-96721597, strand = − BCAT1 chr12: 25055868-25055986, strand = −BCL2L11 chr2: 111876620-111876759, strand = − BHLHE23 chr20:61638462-61638546, strand = − BIN2 chr12: 51717898-51717971, strand = −BIN2_Z chr12: 51718088-51718165, strand = + CAPN2 chr1:223936858-223936998, strand = + chr17_737 chr17: 73749814-73749919,strand = − chr5_132 chr5: 132161371-132161482, Strand = + chr7_636 chr7:104581684-104581817, Strand = − CYP26C1 chr10: 94822396-94822502, strand= + DIDO1 chr20: 61560669-61560753, strand = − DLX4 chr17:48042426-48042820, strand = − DMRTA2 chr1: 50884390-50884519, strand = −DNMT3A chr2: 25499967-25500072, strand = − DOCK2 chr5: 169064370-169064454, strand = − EMX1 chr2: 73147685-73147792, strand = + FAM59Bchr2: 26407701-26407828, strand = + FERMT3 chr11: 63974820-63974959,strand = + FGF14 chr13: 103046888-103046991, strand = + FLJ34208 chr3:194208249-194208355, strand = + FLJ45983 chr10: 8097592-8097699, strand= + GRIN2D chr19: 48918160-48918300, strand = − HIST1H2BE chr6:26184248-26184340, strand = + HOXA9 chr7: 27205002-27205102, strand = −HOXB2 chr17: 46620545-46620639, strand = − KLHDC7B chr22:50987199-50987256, strand = + LOC100129726 chr2: 43451705-43451810,strand = + MATK chr19: 3786127-3786197, strand = +MAX.chr10.22541891-22541946 chr10: 22541881-22541975, strand = +MAX.chr10.22624430-22624544 chr10: 22624411-22624553, strand = −MAX.chr12.52652268-52652362 chr12: 52652262-52652377, strand = −MAX.chr16.50875223-50875241 chr16: 50875167-50875274, strand = −MAX.chr19.16394489-16394575 chr19: 16394457-16394593, strand = −MAX.chr19.37288426-37288480 range = chr19: 37288396-37288512, strand = −MAX.chr8.124173236-124173370 chr8: 124173231-124173386, strand = −MAX.chr8.145105646-145105653 chr8: 145105572-145105685, strand = −MAX_Chr1.110 chr1: 110627118-110627224 strand = − NFIX chr19:13207426-13207513, strand = + NKX2-6 chr8: 23564052-23564145, strand = −OPLAH chr8: 145106777-145106865, strand = − PARP15 chr3:122296692-122296805, strand = + PRDM14 chr8: 70981945-70982039, strand =− PRKAR1B chr7: 644172-644237, strand = + PRKCB_28 chr16:23847607-23847698, strand = − PTGDR chr14: 52735270-52735400, strand = −PTGDR_9 chr14: 52735221-52735300, strand = + RASSF1 chr3:50378408-50378550, strand = − SHOX2 chr3: 157821263-157821382, strand =− SHROOM1 chr5: 132161371-132161425, strand = + SIPR4 chr19:3179921-3180068 strand = − SKI chr1: 2232328-2232423, strand = + SLC12A8chr3: 124860704-124860791, strand = + SOBP chr6: 107956176-107956234,strand = + SP9 chr2: 175201210-175201341, strand = − SPOCK2 chr10:73847236-73847324, strand = − ST8SIA1 chr12: 22487518-22487630, strand= + ST8SIA1_22 chr12: 22486873-22487009, strand = − SUCLG2 chr3:67706477-677065610, strand = − TBX15 Region 1 chr1: 119527066-119527655,strand = + TBX15 Region 2 chr1: 119532813-119532920 strand = − TRH chr3:129693481-129693580, strand = + TSC22D4 chr7: 100075328-100075445,strand = − ZDHHC1 chr16: 67428559-67428628, strand = − ZMIZ1 chr10:81002910-81003005, strand = + ZNF132 chr19: 58951403-58951529, strand =− ZNF329 chr19: 58661889-58662028, strand = − ZNF671 chr19:58238790-58238906, strand = + ZNF781 ch19 : 38183018-38183137, strand =−Analyzing Selected Markers for Cross-Reactivity with Buffy Coat.

1) Buffy Coat Screening

Markers from the list above were screened on DNA extracted from buffycoat obtained from 10 mL blood of a healthy patient. DNA was extractedusing Promega Maxwell RSC system (Promega Corp., Fitchburg, Wisc.) andconverted using Zymo EZ DNA Methylation™ Kit (Zymo Research, Irvine,Calif.). Using biplexed reaction with bisulfite-converted β-actin DNA(“BTACT”), and using approximately 40,000 strands of target genomic DNA,the samples were tested using a QuARTS flap endonuclease assay asdescribed above, to test for cross reactivity. Doing so, the assays for3 markers showed significant cross reactivity:

% Cross Marker reactivity HIST1H2B 72.93% chr7_636 3495.47% chr5_1320.20%

2) Tissue Screening

264 tissue samples were obtained from various commercial andnon-commercial sources (Asuragen, BioServe, ConversantBio, Cureline,Mayo Clinic, M D Anderson, and PrecisionMed), as shown below in Table 2.

No. of cases Pathology Subtype Details 82 Normal NA 68 smokers, 34 37Normal benign nodule never smokers, 17 7 NSCLC bronchioalveolar smokingunknown 13 NSCLC large cell 2 NSCLC neuroendocrine 42 NSCLC squamouscell 68 NSCLC adenocarcinomas 4 SCLC small cell 9 NSCLC carcinoid

Tissue sections were examined by a pathologist, who circledhistologically distinct lesions to direct the micro-dissection. Totalnucleic acid extraction was performed using the Promega Maxwell RSCsystem. Formalin-fixed, paraffin-embedded (FFPE) slides were scraped andthe DNA was extracted using the Maxwell® RSC DNA FFPE Kit (#AS1450)using the manufacturer's procedure but skipping the RNase treatmentstep. The same procedure was used for FFPE curls. For frozen punchbiopsy samples, a modified procedure using the lysis buffer from the RSCDNA FFPE kit with the Maxwell® RSC Blood DNA kit (#AS1400) was utilizedomitting the RNase step. Samples were eluted in 10 mM Tris, 0.1 mM EDTA,pH 8.5 and 10 uL were used to setup 6 multiplex PCR reactions.

The following multiplex PCR primer mixes were made at 10× concentration(10×=2 μM each primer):

-   -   Multiplex PCR reaction 1 consisted of each of the following        markers: BARX1,

LOC100129726, SPOCK2, TSC22D4, PARP15, MAX.chr8.145105646-145105653,ST8SIA1_22, ZDHHC1, BIN2_Z, SKI, DNMT3A, BCL2L11, RASSF1, FERMT3, andBTACT.

-   -   Multiplex PCR reaction 2 consisted of each of the following        markers: ZNF671,

ST8SIA1, NKX6-2, SLC12A8, FAM59B, DIDO1, MAX_Chr1.110, AGRN, PRKCB_28,SOBP, and BTACT.

-   -   Multiplex PCR reaction 3 consisted of each of the following        markers: MAX. chr10.22624430-22624544, ZMIZ1,        MAX.chr8.145105646-145105653, MAX.chr10.22541891-22541946,        PRDM14, ANGPT1, MAX.chr16.50875223-50875241, PTGDR_9, ANKRD13B,        DOCK2, and BTACT.    -   Multiplex PCR reaction 4 consisted of each of the following        markers: MAX.chr19.16394489-16394575, HOXB2, ZNF132,        MAX.chr19.37288426-37288480, MAX.chr12.52652268-52652362,        FLJ45983, HOXA9, TRH, SP9, DMRTA2, and BTACT.    -   Multiplex PCR reaction 5 consisted of each of the following        markers: EMX1, ARHGEF4, OPLAH, CYP26C1, ZNF781, DLX4, PTGDR,        KLHDC7B, GRIN2D, chr17_737, and BTACT.    -   Multiplex PCR reaction 6 consisted of each of the following        markers: TBX15,

MATK, SHOX2, BCAT1, SUCLG2, BIN2, PRKAR1B, SHROOM1, S1PR4, NFIX, andBTACT.

Each multiplex PCR reaction was setup to a final concentration of 0.2 μMreaction buffer, 0.2 μM each primer, 0.05 μM Hotstart Go Taq (5U/μL),resulting in 40 μL, of master mix that was combined with 10 μL of DNAtemplate for a final reaction volume of 50 μL.

The thermal profile for the multiplex PCR entailed a pre-incubationstage of 95° for 5 minutes, 10 cycles of amplification at 95° for 30seconds, 64° for 30 seconds, 72° for 30 seconds, and a cooling stage of4° that was held until further processing. Once the multiplex PCR wascomplete, the PCR product was diluted 1:10 using a diluent of 20 ng/μLof fish DNA (e.g., in water or buffer, see US Pat. No. 9,212,392,incorporated herein by reference) and 10 μL of diluted amplified samplewere used for each QuARTS assay reaction.

Each QuARTS assay was configured in triplex form, consisting of 2methylation markers and BTACT as the reference gene.

-   -   From multiplex PCR product 1, the following 7 triplex QuARTS        assays were run: (1) BARX1, LOC100129726, BTACT; (2) SPOCK2,        TSC22D4, BTACT; (3) PARP15, MAXchr8145105646-145105653,        BTACT; (4) ST8SIA1_22, ZDHHC1, BTACT; (5) BIN2_Z, SKI,        BTACT; (6) DNMT3A, BCL2L11, BTACT; (7) RASSF1, FERMT3, and        BTACT.    -   From multiplex PCR product 2, the following 5 triplex QuARTS        assays were run: (1) ZNF671, ST8SIA1, BTACT; (2) NKX6-2,        SLC12A8, BTACT; (3) FAM59B, DIDO1, BTACT; (4) MAX_Chr1110, AGRN,        BTACT; (5) PRKCB_28, SOBP, and BTACT.    -   From multiplex PCR product 3, the following 5 triplex QuARTS        assays were run: (1) MAXchr1022624430-22624544, ZMIZ1,        BTACT; (2) MAXchr8145105646-145105653,        MAXchr1022541891-22541946, BTACT; (3) PRDM14, ANGPT1, BTACT; (4)        MAXchr1650875223-50875241, PTGDR_9, BTACT; (5) ANKRD13B, DOCK2,        and BTACT.    -   From multiplex PCR product 4, the following 5 triplex QuARTS        assays were run: (1) MAXchr1916394489-16394575, HOXB2,        BTACT; (2) ZNF132, MAXchr1937288426-37288480, BTACT; (3)        MAXchr1252652268-52652362, FLJ45983, BTACT; (4) HOXA9, TRH,        BTACT; (5) SP9, DMRTA2, and BTACT.    -   From multiplex PCR product 5, the following 5 triplex QuARTS        assays were run: (1) EMX1, ARHGEF4, BTACT; (2) OPLAH, CYP26C1,        BTACT; (3) ZNF781, DLX4, BTACT; (4) PTGDR, KLHDC7B, BTACT; (5)        GRIN2D, chr17_737, and BTACT.    -   From multiplex PCR product 6, the following 5 triplex QuARTS        assays were run: (1) TBX15, MATK, BTACT; (2) SHOX2, BCAT1,        BTACT; (3) SUCLG2, BIN2, BTACT; (4) PRKAR1B, SHROOM1, BTACT; (5)        S1PR4, NFIX, and BTACT.

3) Data Analysis:

For tissue data analysis, markers that were selected based on RRBScriteria with <0.5% methylation in normal tissue and >10% methylation incancer tissue were included. This resulted in 51 markers for furtheranalysis.

To determine marker sensitivities, the following was performed:

-   -   1. % methylation for each marker was computed by dividing strand        values obtained for that specific marker by the strand values of        ACTB ((β-actin).    -   2. The maximum % methylation for each marker was determined on        normal tissue. This is defined as 100% specificity.    -   3. The cancer tissue positivity for each marker was determined        as the number of cancer tissues that had greater than the        maximum normal tissue % methylation for that marker.

The sensitivities for the 51 markers are shown below.

TABLE 2 Maximum % methylation for Cancer (N = 136) Marker normal #Negative # Positive sensitivity BARX1 1.665 66 70 51% LOC100129726 1.847109 27 20% SPOCK2 0.261 86 50 37% TSC22D4 0.618 70 66 49% MAX.chr8.1240.293 45 91 67% RASSF1 1.605 79 57 42% ZNF671 0.441 73 63 46% ST8SIA11.56 119 17 13% NKX6_2 15.58 102 34 25% FAM59B 0.433 85 51 38% DIDO12.29 93 43 32% MAX_Chr1.110 0.076 85 51 38% AGRN 2.16 66 70 51% SOBP38.5 110 26 19% MAX_chr10.226 0.7 52 84 62% ZMIZ1 0.025 72 64 47%MAX_chr8.145 5.56 57 79 58% MAX_chr10.225 0.77 72 64 47% PRDM14 0.22 35101 74% ANGPT1 1.6 99 37 27% MAX.chr16.50 0.27 92 44 32% PTGDR_9 4.62 8254 40% ANKRD13B 7.03 93 43 32% DOCK2 0.001 71 65 48% MAX_chr19.163 0.6156 80 59% ZNF132 1.3 83 53 39% MAX chr19.372 0.676 79 57 42% HOXA9 16.753 83 61% TRH 2.64 61 75 55% SP9 14.99 75 61 45% DMRTA2 7.9 55 81 60%ARHGEF4 7.41 113 23 17% CYP26C1 39.2 101 35 26% ZNF781 5.28 44 92 68%PTGDR 6.13 76 60 44% GRIN2D 16.1 113 23 17% MATK 0.04 93 43 32% BCAT10.64 75 61 45% PRKCB_28 1.68 57 79 58% ST8SIA_22 1.934 55 81 60%FLJ45983 8.34 39 97 71% DLX4 15.1 41 95 70% SHOX2 7.48 32 104 76% EMX111.34 34 102 75% HOXB2 0.114 61 75 55% MAX.chr12.526 5.58 34 102 75%BCL2L11 10.7 44 92 68% OPLAH 5.11 29 107 79% PARP15 3.077 42 94 69%KLHDC7B 8.86 38 98 72% SLC12A8 0.883 34 102 75%

Combinations of markers may be used to increase specificity andsensitivity. For example, a combination of the 8 markers SLC12A8,KLHDC7B, PARP15, OPLAH, BCL2L11, MAX.chr12.526, HOXB2, and EMX1 resultedin 98.5% sensitivity (134/136 cancers) for all of the cancer tissuestested, with 100% specificity.

In some embodiments, markers are selected for sensitive and specificdetection associated with a particular type of lung cancer tissue, e.g.,adenocarcinoma, large cell carcinoma, squamous cell carcinoma, or smallcell carcinoma, e.g., by use of markers that show sensitivity andspecificity for particular cancer types or combinations of types.

This panel of methylated DNA markers assayed on tissue achievesextremely high discrimination for all types of lung cancer whileremaining negative in normal lung tissue and benign nodules. Assays forthis panel of markers can be also be applied to blood or bodilyfluid-based testing, and finds applications in, e.g., lung cancerscreening and discrimination of malignant from benign nodules.

Example 3 Testing a 30-Marker Set on Plasma Samples

From the list of markers in Example 2, 30 markers were selected for usein testing DNA from plasma samples from 295 subjects (64 with lungcancer, 231 normal controls. DNA was extracted from 2 mL of plasma fromeach subject and treated with bisulfite as described in Example 1.Aliquots of the bisulfite-converted DNA were used in two multiplexQuARTS assays, as described in Example 1. The markers selected foranalysis are:

-   -   1. BARX1    -   2. BCL2L11    -   3. BIN2_Z    -   4. CYP26C1    -   5. DLX4    -   6. DMRTA2    -   7. DNMT3A    -   8. EMX1    -   9. FERMT3    -   10. FLJ45983    -   11. HOXA9    -   12. KLHDC7B    -   13. MAX.chr10.22624430-22624544    -   14. MAX.chr12.52652268-52652362    -   15. MAX.chr8.124173236-124173370    -   16. MAX.chr8.145105646-145105653    -   17. NFIX    -   18. OPLAH    -   19. PARP15    -   20. PRKCB 28    -   21. S1PR4    -   22. SHOX2    -   23. SKI    -   24. SLC12A8    -   25. SOBP    -   26. SP9    -   27. SUCLG2    -   28. TBX15    -   29. ZDHHC1    -   30. ZNF781

The target sequences, bisulfite converted target sequences, and theassay oligonucleotides for these markers were as shown in FIG. 1. Theprimers and flap oligonucleotides (probes) used for each convertedtarget were as follows:

TABLE 3 Marker Oligonucleotide Name Component Sequence (5′-3′) BARX1BARX1_FP Forward Primer CGTTAATTTGTTAGATAGAGGGCG BARX1_RP Reverse PrimerACGATCGTCCGAACAACC BARX1_PB_A5 Flap Oligo. CCACGGACGCGCCTACGAAAA/3C6/SLC12A8 SLC12A8_FP Forward Primer GGTTTTTTATTTTTGGATTAGCGATCGASLC12A8_RP Reverse Primer CGCTAACTATTCTCGATTACGC SLC12A8_Pb_A1Flap Oligo. CGCCGAGGACGATTAGTTAG/3C6/ PARP15 PARP15_FP Forward PrimerGGTTGAGTTTGGGGTTCG PARP15_RP Reverse Primer CGTAACGTAAAATCTCTACGCCCPARP15_Pb_A5 Flap Oligo. CCACGGACGCGCTCGAACTAC/3C6/ MAX.Chr8.124MAX.Chr8.124_FP Forward Primer GGTTGAGGTTTTCGGGTTTTTAG MAX.Chr8.124_RPReverse Primer CCTCCCCACGAAATCGC MAX.Chr8.124_Pb_A1 Flap Oligo.CGCCGAGGGCGGGTTTTCGT/3C6/ SHOX2 SHOX2_FP Forward PrimerGTTCGAGTTTAGGGGTAGCG SHOX2_RP Reverse Primer CCGCACAAAAAACCGCASHOX2_Pb_A5 Flap Oligo. CCACGGACGATCCGCAAACGC/3C6/ ZDHHC1 ZDHHC1FPForward Primer GTCGGGGTCGATAGTTTACG ZDHHC1RP_V3 Reverse PrimerACTCGAACTCACGAAAACG ZDHHC1Probe_v3_A1 Flap Oligo.CGCCGAGGGACGAACGCACG/3C6/ BIN2_Z BIN2_FP_Z Forward PrimerGGGTTTATTTTTAGGTAGCGTTCG BIN2_RP_Z Reverse PrimerCGAAATTTCGAACAAAAATTAAAACTCGA BIN2_Pb_A5_Z Flap Oligo.CCACGGACGGTTCGAGGTTAG/3C6/ SKI SKI_FP Forward PrimerACGGTTTTTTCGTTATTTTTACGGG SKI_RP Reverse Primer CAACGCCTAAAAACACGACTCSKI_Pb_A1 Flap Oligo. CGCCGAGGGGCGGTTGTTGG/3C6/ DNMT3A DNMT3A_FPForward Primer GTTACGAATAAAGCGTTGGCG DNMT3A_RP Reverse PrimerAACGAAACGTCTTATCGCGA DNMT3A_Pb_A5 Flap Oligo. CCACGGACGGAGTGCGCGTTC/3C6/BC2L11 BCL2L11_FP Forward Primer CGTAATGTTTCGCGTTTTTCG BCL2L11_RPReverse Primer ACTTTCTTCTACGTAATTCTTTTCCGA BCL2L11_Pb_A1 Flap Oligo.CGCCGAGGGCGGGGTCGGGC/3C6/ TBX15 TBX15_Reg2_FP Forward PrimerAGGAAATTGCGGGTTTTCG TBX15_Reg2_RP Reverse PrimerCCAAAAATCGTCGCTAAAAATCAAC TBX15_Reg2_Pb_A5 Flap Oligo.CCACGGACGCGCGCATTCACT/3C6/ FERMT3 FERMT3_FP Forward PrimerGTTTTCGGGGATTATATCGATTCG FERMT3_RP Reverse Primer CCCAATAACCCGCAAAATAACCFERMT3_Pb_A1 Flap Oligo. CGCCGAGGCGACTCGACCTC/3C6/ PRKCB_28 PRKCB_28_FPForward Primer GGAAGGTGTTTTGCGCG PRKCB_28_RP Reverse PrimerCTTCTACAACCACTACACCGA PRKCB_28_Pb_A5 Flap Oligo.CCACGGACGGCGCGCGTTTAT/3C6/ SOBP_HM SOBP_HM_FP Forward PrimerTTTCGGCGGGTTTCGAG SOBP_HM_RP Reverse Primer CGTACCGTTCACGATAACGTSOBP_HM_Pb_A1 Flap Oligo. CGCCGAGGGGCGGTCGCGGT/3C6/ MAX.chr8.145MAX.Chr8.145_FP Forward Primer GCGGTATTAGTTAGAGTTTTAGTCG MAX.Chr8.145_RPReverse Primer ACAACCCTAAACCCTAAATATCGT MAX.Chr8.145_Pb_A5 Flap Oligo.CCACGGACGGACGGCGTTTTT/3C6/ MAX.chr10.226 MAX.Chr10.226_FP Forward PrimerGGGAAATTTGTATTTCGTAAAATCG MAX.Chr10.226_RP Reverse PrimerACAACTAACTTATCTACGTAACATCGT MAX_Chr10.226_Pb_A1 Flap Oligo.CGCCGAGGGCGGTTAAGAAA/3C6/ MAX.chr12.52 MAX.Chr12.52_FP Forward PrimerTCGTTCGTTTTTGTCGTTATCG MAX.Chr12.52_RP Reverse PrimerAACCGAAATACAACTAAAAACGC MAX.Chr12.52PbA1 Flap Oligo.CCACGGACGCGAACCCCGCAA/3C6/ FLI45983 FLI45983_FP Forward PrimerGGGCGCGAGTATAGTCG FLI45983_RP Reverse Primer CAACGCGACTAATCCGCFLI45983_Pb_A1 Flap Oligo. CGCCGAGGCCGTCACCTCCA/3C6/ HOXA9 HOXA9_FPForward Primer TTGGGTAATTATTACGTGGATTCG HOXA9_RP Reverse PrimerACTCATCCGCGACGTC HOXA9_Pb_A5 Flap Oligo. CCACGGACGCGACGCCCAACA/3C6/ EMX1EMX1_FP Forward Primer GGCGTCGCGTTTTTTAGAGAA EMX1_RP Reverse PrimerTTCCTTTTCGTTCGTATAAAATTTCGTT EMX1PbA1 Flap Oligo.CGCCGAGGATCGGGTTTTAG/3C6/ SP9 SP9_FP Forward PrimerTAGCGTCGAATGGAAGTTCGA SP9_RP Reverse Primer GCGCGTAAACATAACGCACCSP9_Pb_A5 Flap Oligo. CCACGGACGCCGTACGAATCC/3C6/ DMRTA2 DMRTA2_FPForward Primer TGGTGTTTACGTTCGGTTTTCGT DMRTA2_RP Reverse PrimerCCGCAACAACGACGACC DMRTA2_Pb_A1 Flap Oligo. CGCCGAGGCGAACGATCACG/3C6/OPLAH FPrimerOPLAH Forward Primer cGTcGcGTTTTTcGGTTATACG RPrimerOPLAHReverse Primer CGCGAAAACTAAAAAACCGCG ProbeA5OPLAH Flap Oligo.CCACGGACG-GCACCGTAAAAC/3C6/ CYP26C1 CYP26C1_FP Forward PrimerTGGTTTTTTGGTTATTTCGGAATCGT CYP26C1_RP Reverse Primer GCGCGTAATCAACGCTAACCYP26C1_Pb_A1 Flap Oligo. CGCCGAGGCGACGATCTAAC/3C6/ ZNF781ZNF781F.primer Forward Primer CGTTTTTTGTTTTTCGAGTGCG ZNF781R.primerReverse Primer TCAATAACTAAACTCACCGCGTC ZNF781probe.A5 Flap Oligo.CCACGGACGGCGGATTTATCG/3C6/ DLX4 DLX4_FP Forward PrimerTGAGTGCGTAGTGTTTTCGG DLX4_RP Reverse Primer CTCCTCTACTAAAACGTACGATAAACADLX4_Pb_A1 Flap Oligo. CGCCGAGGATCGTATAAAAC/3C6/ SUCLG2 SUCLG2_HM_FPForward Primer TCGTGGGTTTTTAATCGTTTCG SUCLG2_HM_RP Reverse PrimerTCACGCCATCTTTACCGC SUCLG2_HM_Pb_A5 Flap Oligo.CCACGGACGCGAAAATCTACA/3C6/ KLHDC7B KLHDC7B_FP Forward PrimerAGTTTTCGGGTTTTGGAGTTCGTTA KLHDC7B_RP Reverse Primer CCAAATCCAACCGCCGCKLHDC7B_Pb_A1 Flap Oligo. CGCCGAGGACGGCGGTAGTT/3C6/ S1PR4_HM S1PR4_HM_FPForward Primer TTATATAGGCGAGGTTGCGT S1PR4_HM_RP Reverse PrimerCTTACGTATAAATAATACAACCACCGAATA S1PR4_HM_Pb_A5 Flap Oligo.CCACGGACGACGTACCAAACA/3C6/ NFIX_HM NFIX_HM_FP Forward PrimerTGGTTCGGGCGTGACGCG NFIX_HM_RP Reverse Primer TCTAACCCTATTTAACCAACCGANFIX_HM_Pb_A1 Flap Oligo. CGCCGAGGGCGGTTAAAGTG/3C6/ Reference DNAsOligonucleotide Name Component Sequence (5′-3′) Zebrafish ZF_RASSF1_FPBT Forward TGCGTATGGTGGGCGAG Synthetic Primer (RASSF1) ZF_RASSF1_RPBT Reverse Primer CCTAATTTACACGTCAACCAATCGAA BT converted)^(†)ZF_RASSF1_Pb_A5 BT Flap Oligo. CCACGGACGGCGCGTGCGTTT/3C6/ B3GALT6*B3GALT6_FP_V2 Forward Primer GGTTTATTTTGGTTTTTTGAGTTTTCGG B3GALT6_RPReverse Primer TCCAACCTACTATATTTACGCGAA B3GALT6_Pb_A1 Flap Oligo.CCACGGACGGCGGATTTAGGG/3C6/ BTACT ACTB_BT_FP65 Forward PrimerGTGTTTGTTTTTTGATTAGGTGTTTAAGA ACTB_BT_RP65 Reverse PrimerCTTTACACCAACCTCATAACCTTATC ACTBBTPbA3 Flap Oligo.GACGCGGAGATAGTGTTGTGG/3C6/ *The B3GALT6 marker is used as both a cancermethylation marker and as a reference target. See U.S. PatentApplication Ser. No. 62/364,082, filed Jul. 19, 2016, which isincorporated herein by reference in its entirety. ^(†)For zebrafishreference DNA see U.S. Patent Application Ser. No. 62/364,049, filedJul. 19, 2016, which is incorporated herein by reference in itsentirety.

The DNA prepared from plasma as described above was amplified in twomultiplexed pre-amplification reactions, as described in Example 1. Themultiplex pre-amplification reactions comprised reagents to amplify thefollowing marker combinations.

TABLE 4 Multiplex Mix 1 Multiplex Mix 2 B3GALT6 (reference) B3GALT6(reference) ZF_RASSF1 (reference) ZF_RASSF1 (reference) BARX1 CYP26C1BCL2L11 DLX4 BCL2L11 DMRTA2 BIN2_Z EMX1 DNMT3A HOXA9 FERMT3 KLHDC7BPARP15 MAX.chr8.125 PRKCB_28 MAX_chr10.226 SHOX2 NFIX SLC12A8 OPLAH SOBPS1PR4 TBX15_Reg2 SP9 ZDHHC1 SUCLG2 ZNF781

Following pre-amplification, aliquots of the pre-amplified mixtures werediluted 1:10 in 10 mM Tris HC1, 0.1 mM EDTA, then were assayed intriplex QuARTS PCR-flap assays, as described in Example 1. The Group 1triplex reactions used pre-amplified material from Multiplex Mix 1, andthe Group 2 reactions used the pre-amplified material from Multiplex Mix2. The triplex combinations were as follows:

Group 1:

ZF_RASSF1-B3GALT6-BTACT (ZBA Triplex) BARX1-SLC12A8-BTACT (BSA2 Triplex)PARP15-MAX.chr8.124-BTACT (PMA Triplex) SHOX2-ZDHHC1-BTACT (SZA2Triplex) BIN2_Z-SKI-BTACT (BSA Triplex) DNMT3A-BCL2L11-BTACT (DBATriplex) TBX15-FERMT3-BTACT (TFA Triplex) PRKCB_28-SOBP-BTACT (PSA2Triplex)

Group 2:

ZF_RASSF1-B3GALT6-BTACT (ZBA Triplex) MAX.chr8.145-MAX_chr10.226-BTACT(MMA2 Triplex) MAX.chr12.526-FLJ45983-BTACT (MFA Triplex)HOXA9-EMX1-BTACT (HEA Triplex) SP9-DMRTA2-BTACT (SDA Triplex)OPLAH-CYP26C1-BTACT (OCA Triplex) ZNF781-DLX4-BTACT (ZDA Triplex)SUCLG2-KLHDC7B-BTACT (SKA Triplex) S1PR4-NFIX-BTACT (SNA Triplex)

Each triplex acronym uses the first letter of each gene name (forexample, the combination of HOXA9−EMX1−BTACT=“HEA”). If an acronym isrepeated for a different combination of markers or from anotherexperiment, the second grouping having that acronym includes the number2. The dye reporters used on the FRET cassettes for each member of thetriplexes listed above is FAM-HEX-Quasar670, respectively.

Plasmids containing target DNA sequences were used to calibrate thequantitative reactions. For each calibrator plasmid, a series of 10×calibrator dilution stocks, having from 10 to 10⁶ copies of the targetstrand per pl in fish DNA diluent (20 ng/mL fish DNA in 10 mM Tris-HCl ,0.1 mM EDTA) were prepared. For triplex reactions, a combined stockhaving plasmids that contain each of the targets of the triplex wereused. A mixture having each plasmid at 1×10⁵ copies per μL was preparedand used to create a 1:10 dilution series. Strands in unknown sampleswere back calculated using standard curves generated by plotting Cp vsLog (strands of plasmid).

Using receiver operating characteristic (ROC) curve analysis, the areaunder the curve (AUC) for each marker was calculated and is shown in thetable below, sorted by Upper 95 Pct Coverage Interval.

TABLE 5 Sensitivity at Marker Name AUC 90% specificity CYP26C1 0.940 80%SOBP 0.929 80% SHOX2 0.905 73% SUCLG2 0.905 64% NFIX 0.895 63% ZDHHC10.890 69% BIN2_Z 0.872 59% DLX4 0.856 56% FLJ45983 0.834 67% HOXA9 0.82453% TBX15 0.813 53% ACTB 0.803 50% S1PR4 0.802 55% SP9 0.782 38% FERMT30.773 36% ZNF781 0.769 55% B3GALT6 0.746 39% BTACT 0.742 44% BCL2L110.732 39% PARP15 0.673 31% DNMT3A 0.689 20% MAX.chr12.526 0.668 33%MAX.chr10.226 0.671 30% SLC12A8 0.655 19% BARX1 0.663 25% KLHDC7B 0.60410% OPLAH 0.571 14% MAX.chr8.145 0.572 16% SKI 0.521 14%

The markers worked very well in distinguishing samples from cancerpatients from samples from normal subjects (see ROC table, above). Useof the markers in combination improved sensitivity. For example, using alogistic fit of the data and a six-marker fit, ROC curve analysis showsan AUC=0.973.

Using a 6-marker fit, sensitivity of 92.2% is obtained at 93%specificity. The group of 6 markers that together resulted in the bestfit was SHOX2, SOBP, ZNF781, BTACT, CYP26C1, and DLX4 (see FIG. 7).Using SHOX2, SOBP, ZNF781, CYP26C1, SUCLG2, and SKI gave an ROC curvewith AUC of 0.97982 (see FIG. 8).

Example 4

Archival plasmas from a second independent study group were tested inblinded fashion. Lung cancer cases and controls (apparently healthysmokers) for each group were balanced on age and sex (23 cases, 80controls). Using multiplex PCR followed by QuARTS (QuantitativeAllele-Specific Real-time Target and Signal amplification) assay asdescribed in Example 1, a post-bisulfite quantification of methylatedDNA markers on DNA extracted from plasma was performed. Top individualmethylated markers from Example 3 were tested in this experiment toidentify optimal marker panels for lung cancer detection (2 ml/patient).

Results: 13 high performance methylated DNA markers were tested(CYP26C1, SOBP, SUCLG2, SHOX2, ZDHHC1, NFIX, FLJ45983, HOXA9, B3GALT6,ZNF781, SP9, BARX1, and EMX1). Data were analyzed using two methods: alogistic regression fit and a regression partition tree approach. Thelogistic fit model identified a 4-marker panel (ZNF781, BARX1, EMX1, andSOBP) with an AUC of 0.96 and an overall sensitivity of 91% and 90%specificity. Analysis of the data using a regression partition treeapproach identified 4 markers (ZNF781, BARX1, EMX1, and HOXA9) with AUCof 0.96 and an overall sensitivity of 96% and specificity of 94%. Forboth approaches, B3GALT6 was used as a standardizing marker of total DNAinput. These panels of methylated DNA markers assayed in plasma achievedhigh sensitivity and specificity for all types of lung cancer.

Example 5 Differentiating Lung Cancers

Using the methods described above, methylation markers are selected thatexhibit high performance in detecting methylation associated withspecific types of lung cancer.

For a subject suspected of having lung cancer, a sample is collected,e.g., a plasma sample, and DNA is isolated from the sample and treatedwith bisulfite reagent, e.g., as described in Example 1. The convertedDNA is analyzed using a multiplex PCR followed by QuARTS flapendonuclease assay as described in Example 1, configured to providedifferent identifiable signals for different methylation markers orcombinations of methylation markers, thereby providing data setsconfigured to specifically identify the presence of one or moredifferent types of lung carcinoma in the subject (e.g., adenocarcinoma,large cell carcinoma, squamous cell carcinoma, and/or small cellcarcinoma). In preferred embodiments, a report is generated indicatingthe presence or absence of an assay result indicative of the presence oflung carcinoma and, if present, further indicative of the presence ofone or more identified types of lung carcinoma. In some embodiments,samples from a subject are collected over the course of a period of timeor a course of treatment, and assay results are compared to monitorchanges in the cancer pathology.

Marker and marker panels sensitive to different types of lung cancerfind use, e.g., in classifying type(s) of cancer present, identifyingmixed pathologies, and/or in monitoring cancer progression over timeand/or in response to treatment.

All literature and similar materials cited in this application,including but not limited to, patents, patent applications, articles,books, treatises, and internet web pages are expressly incorporated byreference in their entirety for any purpose. Unless defined otherwise,all technical and scientific terms used herein have the same meaning asis commonly understood by one of ordinary skill in the art to which thevarious embodiments described herein belongs. When definitions of termsin incorporated references appear to differ from the definitionsprovided in the present teachings, the definition provided in thepresent teachings shall control.

Various modifications and variations of the described compositions,methods, and uses of the technology will be apparent to those skilled inthe art without departing from the scope and spirit of the technology asdescribed. Although the technology has been described in connection withspecific exemplary embodiments, it should be understood that theinvention as claimed should not be unduly limited to such specificembodiments. Indeed, various modifications of the described modes forcarrying out the invention that are obvious to those skilled inpharmacology, biochemistry, medical science, or related fields areintended to be within the scope of the following claims.

1. A method of processing a sample, the method comprising: a) assaying asample from a subject for an amount of at least one methylation markerselected from the group consisting of BARX1, LOC100129726, SPOCK2,TSC22D4, MAX.chr8.124, RASSF1, ZNF671, ST8SIA1, NKX6_2, FAM59B, DIDO1,MAX_Chr1.110, AGRN, SOBP, MAX_chr10.226, ZAIIZ1, MAX_chr8.145,MAX_chr10.225, PRDM14, ANGPT1, MAX.chr16.50, PTGDR_9, ANKRD13B, DOCK2,MAX_chr19.163, ZNF132, MAX_chr19.372, HOXA9, TRH, SP9, DMRTA2, ARHGEF4,CYP26C1, ZNF781, PTGDR, GRIN2D, MATK, BCAT1, PRKCB_28, ST8SIA_22,FLJ45983, DLX4, SHOX2, EA/IX1, HOXB2, MAX.chr12.526, BCL2L11, OPLAH,PARP15, KLHDC7B, SLC12A8, BHLHE23, CAPN2, FGF14, FLI34208, B3GALT6,BIN2_Z, DNMT3A, FERMT3, NFIX, S1PR4, SKI, SUCLG2, TBX15, ZDHHC1 andZNF329; b) assaying said sample for an amount of a reference marker; c)comparing the amount of said at least one methylation marker to theamount of reference marker in said sample to determine a methylationstate for said at least one methylation marker in said sample; andoptionally d) generating a record reporting the methylation state forsaid at least one methylation marker in said sample.
 2. The method ofclaim 1, wherein said assaying comprises obtaining a sample comprisingDNA from a subject and treating DNA obtained from the sample with areagent that selectively modifies unmethylated cytosine residues in theobtained DNA to produce modified residues.
 3. The method of claim 1,wherein said at least one methylation marker comprises a methylationmarker selected from the group consisting of SLC12A8, KLHDC7B, PARP 15,OPLAH, BCL2L11, MAX_chr12.526, HOXB2, EMX1, CYP26C1, SOBP, SUCLG2,SHOX2, ZDHHC1, NFIX, FLJ45983, HOXA9, B3GALT6, ZNF781, SP9, BARX1, andSKI.
 4. (canceled)
 5. The method of claim 1, wherein said at least onemethylation marker comprises a group of methylation markers selectedfrom: the group consisting of ZNF781, BARX1, and EMX1; the groupconsisting of SHOX2, SOBP, ZNF781, CYP26C1, SUCLG2, and SKI; the groupconsisting of SLC12A8, KLHDC7B, PARP15, OPLAH, BCL2L11, MAX.chr12.526,HOXB2, and EMX1; the group consisting of SHOX2, SOBP, ZNF781, BTACT,CYP26C1, and DLX4; the group consisting of SHOX2, SOBP, ZNF781, CYP26C1,SUCLG2, and SKI_(L) the group consisting of ZNF781, BARX1, and EN/XL andfurther comprising SOBP and/or HOXA9. 6-8. (canceled)
 9. The method ofclaim 1, wherein assaying the methylation state of a methylation markerin the sample comprises determining the extent of methylation at aplurality of bases. 10-11. (canceled)
 12. The method of claim 1, whereinthe sample is a tissue sample, a blood sample, a serum sample, a plasmasample, or a sputum sample. 13-16. (canceled)
 17. The method of claim 1,wherein said sample is a plasma sample obtained from a subject having orsuspected of having a lung neoplasm, wherein said method comprises: a)combining the plasma sample with: i) protease; and ii) a first lysisreagent, said first lysis reagent comprising guanidine thiocyanate; andnon-ionic detergent; to form a mixture wherein proteins are digested bysaid protease; b) to the mixture of step a) adding iii) silicaparticles, and iv) a second lysis reagent, said second lysis reagentcomprising: guanidine thiocyanate; non-ionic detergent; and isopropylalcohol; under conditions wherein DNA is bound to said silica particles;c) separating silica particles with bound DNA from the mixture of b); d)to the separated silica particles with bound DNA adding a first washsolution, said first wash solution comprising A) guanidine hydrochlorideor guanidine thiocyanate, and B) ethyl alcohol; e) separating the silicaparticles with bound DNA from said first wash solution; f) to theseparated silica particles with bound DNA adding a second wash solution,said second wash solution comprising a buffer and ethyl alcohol; g)separating washed silica particles with bound DNA from said second washsolution; and h) eluting DNA from the washed silica particles with boundDNA separated in step g); i) assaying eluted DNA for an amount of atleast one methylated methylation marker and for an amount of referencemarker in said eluted DNA; j) comparing the amount of said at least onemethylated methylation marker to the amount of reference marker in saidDNA to determine a methylation state for said at least one methylationmarker in said plasma sample; and optionally d) generating a recordreporting the methylation state for said at least one methylation markerin said plasma sample.
 18. (canceled)
 19. The method of claim1, whereinthe assaying comprises using polymerase chain reaction, nucleic acidsequencing, mass spectrometry, methylation specific nuclease, mass-basedseparation, or target capture.
 20. The method of claim 19, wherein theassaying comprises using a flap endonuclease assay.
 21. The method ofclaim 2, wherein the assaying comprises bisulfite converting methylationmarker DNA and reference marker DNA.
 22. The method of claim 21, whereindetermining the methylation level of one or more methylation markers isachieved by a technique selected from the group consisting ofmethylation-specific PCR, quantitative methylation-specific PCR,methylation-sensitive DNA restriction enzyme analysis, quantitativebisulfite pyrosequencing, flap endonuclease assay, and bisulfite genomicsequencing PCR.
 23. The method of claim 17, wherein assaying said elutedDNA comprises analyzing multiple DNA methylation markers using a PCRpre-amplification and a PCR-flap assay by a process comprising: a)providing bisulfite-treated DNA comprising a plurality of different DNAmethylation marker target regions in a first reaction mixture comprisingPCR amplification reagents, wherein said PCR amplification reagentscomprise: i) a plurality of different primer pairs for amplifying saidplurality of different target regions, if present in said sample, fromsaid bisulfite-treated DNA; ii) thermostable DNA polymerase; iii) dNTPs;and iv) a buffer comprising Mg⁺⁺ b) exposing said first reaction mixtureto thermal cycling conditions wherein a plurality of different DNAmethylation marker target regions, if present in the sample, areamplified to produce a pre-amplified mixture, and wherein said thermalcycling conditions are limited to a number of thermal cycles thatmaintain amplification in an exponential range, preferably fewer than20, more preferably fewer than 15, more preferably 10 or fewer thermalcycles; c) partitioning said pre-amplified mixture into a plurality ofPCR-flap assay reaction mixtures, wherein each PCR-flap assay reactionmixture comprises: i) an additional amount of a primer pair selectedfrom said plurality of different primer pairs of step a) i); ii)thermostable DNA polymerase; iii) dNTPs; iv) said buffer comprising Mg⁺⁺v) a flap endonuclease; vi) a flap oligonucleotide, and vi) a hairpinoligonucleotide comprising a region that is complimentary to a portionof said flap oligonucleotide; and d) detecting amplification of one ormore different DNA methylation marker target regions from saidbisulfite-treated DNA during PCR-flap assay reactions.
 24. The method ofclaim 23, wherein said bisulfite-treated DNA is prepared from a plasmasample of at least one mL, and wherein the volume of saidbisulfite-treated DNA comprising a plurality of different DNAmethylation marker target regions in the amplification reaction of stepb is at least 20 to 50% of the total volume of the amplificationreaction.
 25. A kit, comprising: a) at least one oligonucleotide,wherein at least a portion of said oligonucleotide specificallyhybridizes to a methylation marker selected from the group consisting ofBARX1, LOC100129726, SPOCK2, TSC22D4, MAX.chr8.124, RASSF1, ZNF671,ST8SIA1, NKX6_2, FAM59B, DIDO1, MAX_Chr1.110, AGRN, SOBP, MAX_chr10.226,ZAIIZ1, MAX_chr8.145, MAX_chr10.225, PRDM14, ANGPT1, MAX.chr16.50,PTGDR_9, ANKRD13B, DOCK2, MAX_chr19.163, ZNF132, MAX chr19.372, HOXA9,TRH, SP9, DMRTA2, ARHGEF4, CYP26C1, ZNF781, PTGDR, GRIN2D, MATK, BCAT1,PRKCB_28, ST8SIA_22, FLI45983, DLX4, SHOX2, EMX1, HOXB2, MAX.chr12.526,BCL2L11, OPLAH, PARP15, KLHDC7B, SLC12A8, BHLHE23, CAPN2, FGF14,FLI34208, B3GALT6, BIN2_Z, DNMT3A, FERIIT3, NFIX, S1PR4, SKI, SUCLG2,TBX15, ZDHHC1, and ZNF329, and b) at least one additionaloligonucleotide, wherein at least a portion of said additionaloligonucleotide specifically hybridizes to a reference nucleic acid. 26.The kit of claim 25, wherein said portion of said oligonucleotidespecifically hybridizes to a bisulfite-treated DNA comprising saidmethylation marker. 27-30. (canceled)
 31. The kit of claim 25, whereinsaid at least one methylation marker comprises a group of methylationmarkers selected from: the group consisting of ZNF781, BARX1, and EMX1;group consisting of SHOX2, SOBP, ZNF781, CYP26C1, SUCLG2, and SKI; thegroup consisting of SLC12A8, KLHDC7B, PARP15, OPLAH, BCL2L11,MAX.chr12.526, HOXB2, and EMX1; the group consisting of SHOX2, SOBP,ZNF781, BTACT, CYP26C1, and DLX4; the group consisting of SHOX2, SOBP,ZNF781, CYP26C1, SUCLG2, and SKI_(L) the group consisting of ZNF781,BARX1, and EMX1, and further comprising SOBP and/or HOXA9. 32.(canceled)
 33. The kit of claim 25, wherein said oligonucleotide isselected from one or more of a capture oligonucleotide, a pair ofnucleic acid primers, a nucleic acid probe, and an invasiveoligonucleotide. 34-37. (canceled)
 38. A composition comprising areaction mixture comprising a complex of a target nucleic acid selectedfrom the group consisting of BARX1, LOC100129726, SPOCK2, TSC22D4,MAX.chr8.124, RASSF1, ZNF671, ST8SIA1, NKX6_2, FAM59B, DIDO1,MAX_Chr1.110, AGRN, SOBP, MAX_chr10.226, ZAIIZ1, MAX_chr8.145,MAX_chr10.225, PRDM14, ANGPT1, MAX.chr16.50, PTGDR_9, ANKRD13B, DOCK2,MAX_chr19.163, ZNF132, MAX_chr19.372, HOXA9, TRH, SP9, DMRTA2, ARHGEF4,CYP26C1, ZNF781, PTGDR, GRIN2D, MATK, BCAT1, PRKCB_28, ST8SIA_22,FLJ45983, DLX4, SHOX2, EMX1, HOXB2, MAX.chr12.526, BCL2L11, OPLAH,PARP15, KLHDC7B, SLC12a, BHLHE23, CAPN2, FGF14, FLJ34208, B3GALT6,BIN2_Z, DNMT3A, FERMT3, NFIX, S1PR4, SKI, SUCLG2, TBX15, ZDHHC1, andZNF329, and an oligonucleotide that specifically hybridizes to saidtarget nucleic acid. 39-40. (canceled)
 41. The composition of claim 38,wherein said oligonucleotide is selected from one or more of a captureoligonucleotide, a pair of nucleic acid primers, a hybridization probe,a hydrolysis probe, a flap assay probe, and an invasive oligonucleotide.42. The composition of claim 38, wherein said target nucleic acidcomprises a nucleic acid sequence selected from the group consisting ofSEQ ID NOS: 1, 6, 11, 16, 21, 28, 33, 38, 43, 48, 53, 58, 63, 68, 73,78, 86, 91, 96, 101, 106, 111, 116, 121, 126, 131, 136, 141, 146, 151,156, 161, 166, 171, 176, 181, 186, 191, 196, 201, 214, 219, 224, 229,234, 239, 247, 252, 257, 262, 267, 272, 277, 282, 287, 292, 298, 303,308, 313, 319, 327, 336, 341, 346, 351, 356, 361, 366, 371, 384, and403, or wherein said target nucleic acid is bisulfite-converted targetnucleic acid comprising a nucleic acid sequence selected from the groupconsisting of SEQ ID NOS: 2, 7, 12, 17, 22, 29, 34, 39, 44, 49, 54, 59,64, 69, 74, 79, 87, 92, 97, 102, 107, 112, 117, 122, 127, 132, 137, 142,147, 152, 157, 162, 167, 172, 177, 182, 187, 192, 197, 202, 210, 215,220, 225, 230, 235, 240, 248, 253, 258, 263, 268, 273, 278, 283, 288,293, 299, 304, 309, 314, 320, 328, 337, 342, 347, 352, 357, 362, 367,372, 385, and
 404. 43-46. (canceled)
 47. The composition of claim 38,further comprising one or more of a FRET cassette; a FEN-1 endonucleaseand a thermostable DNA polymerase.